Medicare for All Discussion Spirals Into Squabble; and What about Obamacare?

Screen Shot 2019-07-07 at 8.30.22 PM.pngThose of you that were able to stick it out and watch the latest Democrat debates were observers to the shouting match, which erupted between Biden and Castro. I really wonder whether any of the candidates understand health care and what they are all proposing as the solutions!

Shannon Firth the Washington Correspondent for MedPage noted that whether Americans really want a Medicare for All health system, what it would cost, and who among the remaining Democratic presidential candidates has the best plan might have made a thoughtful discussion at Thursday night’s third debate. Americans didn’t see much of that, however.

Instead, the event quickly devolved into personal squabbling that often left the moderators’ and each others’ questions unanswered.

It was the first debate to include only 10 candidates, due to more rigid qualifying requirements set by the Democratic National Committee.

Participants included former Vice President Joe Biden, Sen. Cory Booker (D-N.J.), South Bend, Indiana, Mayor Pete Buttigieg, former Housing and Urban Development Secretary Julián Castro, Sen. Kamala Harris (D-Calif.), Sen. Amy Klobuchar (D-Minn.), former Rep. Beto O’Rourke (D-Texas), Sen. Bernie Sanders (I-Vt.), Sen. Elizabeth Warren (D-Mass.), and businessman Andrew Yang.

Biden led in most polls ahead of the debate, although Warren tied with him in one, and Sanders beat him in another, according to RealClearPolitics.

Paying for Medicare for All

It was Biden, the front-runner, who took the first shot at his opponents when asked whether Sanders’ Medicare for All bill, which Warren also supports, was “pushing too far beyond” what the Democratic party wants.

Biden said voters themselves would decide what the Democratic party wants.

“I know that the senator says she’s for Bernie,” said Biden of Warren. “Well, I’m for Barack,” he said, referring to former President Barack Obama and his landmark Affordable Care Act. “I think the Obamacare worked,” Biden declared.

His plan would “replace everything that’s been cut [under President Trump], add a public option,” and guarantee affordable insurance for everybody. He said it would cost $740 billion. “It doesn’t cost $30 trillion,” he said, alluding to Sanders’ 10-year plan.

“That’s right, Joe,” Sanders responded, confirming his plan would cost that much. But he quickly added, the “status quo over 10 years will be $50 trillion.”

“Every study done shows that Medicare for All is the most cost-effective approach to providing healthcare,” Sanders asserted.

He stressed that his plan would “eliminate all out of pocket expenses, all deductibles, all copayments,” and that no American would pay more than $200 for prescription drugs under his bill.

Biden said that, under his plan, the most an individual would pay out-of-pocket would be $1,000. Under Sanders’ plan, a middle-class individual with three kids would ultimately pay $5,000 more for insurance and 4% more on income taxes.

ABC anchor George Stephanopoulos pressed Warren on whether she would raise taxes for the middle class in order to fund a full Medicare for All plan.

“On Medicare for All, costs are going to go up for wealthier individuals and costs are going to go up for giant corporations, but for hardworking families across this country, costs are going to go down,” Warren replied, without addressing the tax question directly.

Biden also argued that his own plan would not take away health insurance from the 160 million people satisfied with what they have now. Klobuchar, who also wants to keep private insurance available, also attacked Sanders’ and Warren’s plan, suggesting an estimated 149 million Americans would lose their commercial health insurance in 4 years.

“I don’t think that’s a bold idea, I think it’s a bad idea,” Klobuchar said.

“I’ve actually never met anybody who likes their health insurance company,” Warren shot back, to hearty applause.”I’ve met people who like their doctors. I’ve meet people who like their nurses. I’ve met people who like their pharmacists… What they want is access to healthcare.”

Sanders pointed out, too, that 50 million Americans change or lose health insurance every year, when they quit, lose or change jobs, or their employers change policies.

Shouting match

But the substantive debate may not linger in memory as much as a shouting match between Biden and Castro over one aspect of the former vice president’s plan and his statements about it.

The quarrel was short-lived but sent Twitter aflutter for hours. Viewers wondered whether Castro’s remarks were a veiled critique of Biden’s age — Biden is 76, Castro is 44 — as well as whether the criticisms were fair or true.

Castro told ABC News in a post-debate interview, “I wasn’t taking a shot at his age.”

Harris had tried earlier, without much success, to steer the debate toward the candidates’ differences from President Trump, rather than each other.

“Everybody on this stage … is well-intentioned and wants that all Americans have coverage and recognizes that right now 30 million Americans don’t have coverage,” she said. “So, let’s talk about the fact that Donald Trump came into office and spent almost the entire first year of his term trying to get rid of the Affordable Care Act. We all fought against it and then the late, great John McCain, at that moment at about 2 o’clock in the morning, killed his attempt to take healthcare from millions of people in this country.”

That did not put an end to the current administration’s efforts to end the ACA, however, and Harris pointed to the Department of Justice’s moves in court to have it declared unconstitutional.

“But let’s focus on the end goal, if we don’t get Donald Trump out of office, he’s gonna get rid of all of it,” she said.

The other Democrats, however, let the subject drop.

Disabled Activist Calls Out Kamala Harris Over Huge Holes Sen. Kamala Harris (D-Calif.) is holding steadfast in her belief that her version of “Medicare for All” is indeed “the best,” as she said during an August forum.

But, the presidential hopeful’s unwavering defense of her self-drafted health care plan didn’t deter progressive activist, lawyer and author Ady Barkan from pointing out what he found to be glaring flaws in her proposal.

In a nine-minute video capturing his discussion (below) with Harris released on Monday, Barkan, who was diagnosed with ALS in 2016, took Harris to task when he asked her why she was using the phrase “Medicare for All” to describe her plan, when to him, it sounded more like something “closer to a combination of private and public options rather than a single-payer ‘Medicare For All.’”

Unlike Sen. Bernie Sanders’ (I-Vt.) single-payer bill that Harris had previously supported, the California senator’s proposal would give Americans the option of keeping their private health insurance plans. Harris’ plan also includes a 10-year transitory period to phase out privatized insurance, which critics say is too long.

In response, Harris explained that with her plan, “everybody will be covered … and it will be a Medicare system” in which private insurers “have to be in our system … and it will be by our rules.”

That’s when Barkan decided to share why he thinks Sanders’ single-payer bill — which senators and presidential hopefuls Elizabeth Warren of Massachusetts, Cory Booker of New Jersey, and Kirsten Gillibrand of New York also support — is the best approach for reforming the country’s health care system.

Under Harris’ plan, Barkan said, “millions of people like me will still be denied care by their for-profit insurance company” during the 10-year transition period and possibly afterwards. Because of this, Barkan said he believes that people “will avoid getting needed care because of high co-pays and deductibles.”

In his opinion, Sanders’ single-payer plan would drive down “billions of dollars per year in administrative and billing costs,” which are a result of the for-profit system.

“That will not happen if providers still have to bill numerous insurance companies,” he added.

“Finally, there is the political reality,” Barkan concluded. “The insurance industry is going to do everything it can to block any of these proposals, including yours, which means the only way to win is with a huge grassroots movement, and from what I can see, that enthusiasm only exists for ‘Medicare for All.’ So, where am I wrong?”

In response, Harris said that with her “Medicare for All” plan, on Day 1, “you can get into the system of ‘Medicare for All’ and have a public plan, you don’t have to do a private plan. It’s your choice.”

Harris’ answer echoed what she has said in the past of her plan, but many people on Twitter still seemed to enjoy watching Barkan make compelling arguments about what he considered to be holes in her bill.

Doctors alarmed by Trump’s health care plan but confused by Democratic presidential candidates’ plans

Alexander Nazaryan pointed out that a day before Democratic presidential candidates converged here for a primary debate, a half-dozen doctors affiliated with the Committee to Protect Medicare and Affordable Care, a progressive group, held a rally to denounce President Trump and Republicans for what they charged were harmful proposals to strip Americans of health care coverage.

“We are here in Houston because the world is watching,” said Dr. Rob Davidson, the Michigan-based founder of the committee. “The world is watching to see whether the United States, the most powerful country in the world, is going to choose affordable, quality care or they’re going to peel back the social safety net from the elderly, the sick and the middle class.”

He said that Trump administration decisions — such as repealing the Affordable Care Act’s individual mandate — had led to 7 million people losing their health care coverage.

At the same time, some of those doctors expressed confusion and even dismay with Democratic plans. That suggested that while many in the medical community do oppose Trump’s plan to repeal and replace the ACA, they are ambivalent about the plans of his political opponents. And they hoped that, when it came time to debate on Thursday night, those candidates would offer substance instead of platitudes.

“I have to be honest, out of all the politicians I hear talk about health care,” said Davidson, “I don’t know that any of them quite have the grip on it that doctors have.”

Doctors, though, are hardly in agreement. A few, though not many, supported Trump’s ultimately unsuccessful 2017 effort to repeal the ACA, which was President Barack Obama’s signature legislative accomplishment. The American Medical Association has come out against a fully federalized health care system, the proposal of Vermont senator and presidential candidate Bernie Sanders. Some doctors, though, do believe that such a fix is not just possible but necessary.

“I don’t want a single-payer for all of America,” said Dr. Lee Ben-Ami, a Houston family practice doctor who is also affiliated with a local progressive group but was speaking as a private individual. She said she was “a little worried” about the Democratic Party moving toward the Sanders plan, even as she said it was necessary to provide health care to uninsured Americans. Centrist candidates like Sen. Michael Bennet of Colorado have offered such proposals, with a public option, but even though that was regarded as a radical solution during the Obama administration, many progressives now see it as a conservative concession.

Such friction could spell trouble for Democrats, who in the 2018 midterm congressional elections successfully ran on protecting health care from cuts by Republicans. At the time, a tight focus on preserving the ACA allowed for victories even in unlikely districts like the 14th in Illinois, a Republican stronghold won by Lauren Underwood, a first-time candidate who was trained as a nurse. Her opponent had voted to repeal the ACA as a House member.

Even though the doctors at the Houston rally expressed dismay at the Trump administration’s approach to health care, there was no explicit endorsement of a Democratic policy. “I’m very unclear what some of the Democrats believe,” said Ben-Ami, speaking to Yahoo News before the rally. “We’ve got some people saying ‘Medicare for all,’ and what does that mean? And then I have some Democrats where I can’t pinpoint their policy.”

Davidson also lamented the lack of specifics from candidates. “I hope we get more into the weeds” during Thursday’s debate, he told Yahoo News. He hoped candidates avoid “little sound bites that play well on the news.”

Those present at the rally agreed that any Democratic president would be a better custodian of the nation’s complex medical system than Trump. Davidson noted that Republicans have spoken to the president about cutting Medicare as a “second-term project,” should he win reelection next November.

The doctors held their rally on the edge of the Texas Medical Center, the largest such facility in the world. The center is home to the M.D. Anderson Cancer Center — where immunologist James P. Allison was recently awarded a Nobel Prize — as well as five dozen other institutions. At the same time, 22 percent of Houston residents are uninsured, according to the Urban Institute.

Just the day before the rally on Houston’s vast medical campus, Texas was found to be “the most uninsured state in the nation,” as the Texas Tribune put it, describing just-released statistics from the U.S. Census Bureau. The ACA allowed Texas to expand Medicaid, but it was one of 14 states — almost all of them controlled by conservative governors and legislatures — to decline the federal government’s help. That prevented 1.8 million Texans from receiving coverage, Ben-Ami said on Thursday.

Dr. Pritesh Gandhi, an Austin doctor who is running for Congress, agreed that any plan would be better than Trump’s: “Physicians could care less about the semantics of plans.”

Gandhi said he would endorse any Democrat who would push for the uninsured to have insurance. “All we want is for folks who don’t have insurance to get insurance,” he said.

Most Democrats want that too, even if they are deeply divided about how to get there.

Poll of the Day: Democrats Increasingly Favor Obamacare

Yuval Rosenberg of the Fiscal Times reviewed a poll showing that more than eight in 10 Democrats — 84% to be precise — say they view the Affordable Care Act favorably in the latest Kaiser Family Foundation tracking polls. That’s the largest share of Democrats supporting the law in the nine years the tracking poll has been conducted. (Overall, 53% of Americans view the law favorably.) Support for the law among Democrats has risen 11 percentage points since President Trump took office.

The poll also finds that 55% of Democrats and Democratic-leaning independents say they’d prefer a candidate who wants to build on the ACA to expand coverage and lower costs, while 40% say they’d prefer a candidate who wants to replace the law with a national Medicare-for-All system.

Majorities across party lines agree that Congress’s top health care priorities should be lowering prescription drug costs, maintaining protections for patients with pre-existing conditions and reducing what people pay for care. But a partisan split emerges when people are asked to choose whether it’s more important for lawmakers to make sure all Americans have health insurance or to lower health care costs.

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CDC, states update number of cases of lung disease associated with e-cigarette use, or vaping. What is going to take us all to ban these e-cigarettes at least from our youth. How many kids’ death does it take?

Media Statement

CDC today announced the updated number of confirmed and probable cases of lung disease associated with e-cigarette product use, or vaping. The new case count is the first national aggregate based on the new CDC definition developed and shared with states in late August.

Cases

  • As of September 11, 2019, 380 confirmed and probable cases of lung disease associated with e-cigarette product use, or vaping, were reported by 36 states and the U.S. Virgin Islands.
  • The previous case count released by CDC was higher because it reported possible* cases that were still under investigation by states. The current number includes only confirmed** and probable*** cases reported by states to CDC after classification.
  • CDC is no longer reporting possible cases or cases under investigation and states have recently received the new CDC case definition to classify cases. The classification process requires medical record review and discussion with the treating healthcare providers. The current number is expected to increase as additional cases are classified.
  • CDC will continue to report confirmed and probable cases as one number because the two definitions are very similar and this is the most accurate way to understand the number of people affected.

*A possible case is one still under investigation at the state level.

**A confirmed case is someone who recently used an e-cigarette product or vaped, developed a breathing illness, and for whom testing did not show an infection. Other common causes of illness have been ruled out as the primary cause.

***A probable case is someone who recently used an e-cigarette product or vaped, developed a breathing illness, and for whom some tests have been performed to rule out infection. Other common causes of illness have been ruled out as the primary cause.

Deaths

  • Six total deaths have been confirmed in six states: California, Illinois, Indiana, Kansas, Minnesota, and Oregon.

What the CDC is doing

CDC is currently coordinating a multistate investigation. In conjunction with a task force from the Council for State and Territorial Epidemiologists and affected states, interim outbreak surveillance case definitions, data collection tools, and a database to collect relevant patient data have been developed and released to states.

CDC continues to provide technical assistance to states, including working closely with affected states to characterize the exposures and the extent of the outbreak.

CDC is providing assistance in epidemiology, disease surveillance, pathologic consultation, clinical guidance development, and communication.

CDC also continues to work closely with the Food and Drug Administration (FDA) to collect information about recent e-cigarette product use, or vaping, among patients and to test the substances or chemicals within e-cigarette products used by case patients.

So, we can still see that there are really no solutions to the health care problem. Even the Republicans who had the majorities in both the House and the Senate made any headway, even though they promised to come up with a solution. The President also keeps on promising a solution, but nowhere do I see any progress. As you all my have figured out Medicare for All is not the correct solution unless there are clarity on realistic financing, tort reform and how to provide financial assistance for medical education. Help!!

More to come in this discussion.

What Single Payer Healthcare Would Do For American Families; and Do We Need Medicare for All?

medicare360Lizzy Francis of Fatherly noted that Every Democratic frontrunner in the 2020 election has some sort of universal health care plan akin to Medicare for All. While all of their plans “possibly” answer a real question — how to fix a health insurance system that is expensive, confusing, and mired in bureaucracy — they differ in many ways. Meanwhile, pundits and moderate politicians have called single-payer unrealistic and expensive, while arguing that many people really like their private insurance and don’t want to be kicked off of it. Others worry about what it would do to the private health care system, which would be gutted. But the costs of considering single-payer are too big to ignore including the cost of establishing and running a system such as what the Democrats advertise as their solutions.

Today, individually insured middle class families spend about 15.5 percent of their income on health care — not counting what their employees cover in premiums before their pay even hits their paycheck. Meanwhile, the wealthiest Americans actually receive such great tax exemptions for their health care spending that they receive a surplus of .1 percent to .9 percent on top of their income.

“Overall health expenditures throughout the whole economy will go down, due to the efficiencies of a single-payer system,” says Matt Bruenig, lawyer, policy analyst, and founder of the People’s Policy Project, a think tank that studies single-payer healthcare. “And the distribution of those expenditures and who pays for those expenditures will be shifted up the income ladder. Middle class families can expect at least thousands of dollars of savings a year from not having to pay premiums or co-pays,” he says.

Today, families that make about $60,000 a year spend about $10,000 of their pay on health care. Under universal health care, they would pay less than $1,000 in taxes (really??) and no longer have to pay deductibles, deal with surprise billing, or contend with the fact that a major medical event could bankrupt them.

Aside from costs, there are more reasons our current healthcare system is failing families. For example, even someone on employer-sponsored health insurance who might like their health insurance has a one in four chance of getting kicked off of it over the course of any given year. And given that today the average worker has about 11 jobs from age 18 to 50, per Bruenig, health insurance turnover is all but inevitable for the modern worker.

The numbers on insurance turnover are alarming, starting with the fact that about 28 million Americans have no insurance at all. All of these people likely got kicked off of their insurance: the 3.7 million people who turned 65 in 2017, the 22 million people who were fired in 2018, the 40.1 million people who quit their jobs in 2018, and the employees who work at 15 percent of companies with employer-sponsored health insurance that switched carriers, the latter of which changes the providers that employees can see and causes a lot of paperwork. Then one must consider the 1.5 million people who got divorced in 2015 and 7.4 million people who moved states and the 35 percent of people on Medicaid had their income increase to the point where they were too well off for Medicaid but not well off enough to afford other insurance plans.

Beyond that, insurers are constantly changing what providers they work with, which means the doctor that someone sees in April might not be on their plan three months later. Employees and families often feel stuck to their jobs that may have a bad work-life balance, pay poorly, or otherwise not be a good fit because the costs of trying to get on another health care plan or the risks of leaving a job due to the health care plan it offers are far too high when kids are in the mix.

“Having consistency is key, even for people who have jobs,” says Bruenig. “That job will only last so long before they’re off to another one. They could get fired, the company could close down. Being in the labor force and having the security that [your insurance will] follow you no matter which job you go to is useful,” says Bruenig.

It’s especially useful for parents, who have more than their own health to worry about. And even people who have health insurance through their private plan or employer go bankrupt with alarming frequency. Out of pocket spending for people with employer-provided health insurance has increased by more than 50 percent in the last 10 years; half of all insurance policyholders have a deductible of at least $1,000; and most deductibles for families near $3,000. When more than 40 percent of Americans say they cannot afford an emergency expense of $400 or more, it’s a wonder to think how they could ever meet that deductible before their health insurance coverage kicks in. About one in four Americans in a 2015 poll said they could not afford medical bills, and another poll showed that half of those polled had received a medical bill that they could not afford to pay. Medical debt affects 79 million Americans or about half of working-age people.

Two thirds of people who file for bankruptcy say that their inability to pay their medical bills is why they are doing so. These are often people who are insured. These are people who should be protected. They pay into an insurance program — sometimes 20 percent of their income — in order to protect them and their families from this, but insurance companies do not protect them.

One reason is that in medical emergencies, ambulances often take people to the nearest possible hospital. That hospital might not be in their network. Or it might be, but the attending doctor might not be in their network. When the bill comes due, Americans are gutted. That would never happen under a single-payer system.

The average American middle class family spends about 15-20 percent of their income on health care each year. That would shrink to just around 5 percent under many versions of the payment plan, with out-of-pocket costs completely eliminated from the equation and no deductible to discourage families from getting the medical help they need. They could continue to see the providers they like without worrying that their provider will stop working with their insurer. People don’t like to wade through the bureaucracy of their employer sponsored or private insurance plans: they like their doctors. They like having relationships with them. They like to be able to see them without being surprise billed or being told their insurance only covers half of their visits.

But what about business? What single-payer would do to the overall economy is hard to say. Retirement portfolios would surely be affected by the change. The stock market would be affected. People in the health insurance industry could lose their jobs. But many of the companies, which still sell medications and medical tech, would survive, even if the scope of their business would radically change. And for businesses that spend money to insure their employees, there would either be a slight reduction in the cost of business or very little change in cost at all, says Bruenig.

Today, businesses, which help insure 155 million Americans, spend about $1 trillion in premiums to the private health insurance industry. That actually probably wouldn’t change under a single-payer system, per Bruenig.

“The question of the bottom line for businesses, money-wise, is a little bit uncertain. But the idea is not to necessarily save them money — it’s more of a question of flexibility. The objective savings that employers would realize in terms of not having to hire staff to talk to insurers and enroll people in insurance go down a lot. But in general, we want to keep them [paying into the system] instead of trying to shift them off to some other person.”

That’s how employer-sponsored insurance basically works today. What many people don’t realize is that part of the premiums that employers pay for their employees is set aside as part of their salary when they are hired. So, per Bruenig, if someone makes $50,000 a year, that means that about $15,000 on average is set aside from the employer perspective (that employees don’t know about) to pay into the health insurance system while employees cover about 30 percent of that premium cost through their paycheck, not including deductibles and out-of-pocket costs.

While that wouldn’t change under Medicare for All, instead of paying premiums to private insurers, employers would pay those premiums to the government. In the meantime, their costs associated with HR, payroll, and the time spent poring over health care plans would be eliminated.

There are a few ways this can be handled: one is called a ‘maintenance of effort approach,’ which is where employers pay what they were paying under private insurance to the government every year, accounting for inflation.

Another oft-cited method of payment is through an increase in the payroll tax — a tax employers already pay — to the government to help fund government-sponsored health care. Other plans include making the federal income tax more progressive and raising the marginal tax rate to 70 percent to those who make more than $10 million a year and establishing an extreme wealth tax like that proposed by Elizabeth Warren.

Estimates show that Bernie Sanders’ Medicare For All plan would save $5.1 trillion of taxpayer and business money over a decade while cutting out-of-pocket spending on health care. While total health care spending will indeed need to increase as more people will be covered by health care, the overall savings in expenses would bring that cost back down so much that the government only needs to raise about 1 trillion dollars to fund Medicare for All when met with taxpayer money and private business investment. This number has been proven incorrect. The cost is about $40 trillion over 10 years.

But the reasons that it would help employers often go beyond the strictly financial, much how the reasons for universal health care being so great for families to go beyond the financial benefits as well.

“In the current system, mandates trigger based on if someone is a full-time employee. To the extent that that goes away, you would expect that you won’t have a big employer making sure people only work 29 hours so that [they don’t get benefits.],” argues Bruenig. “Essentially, those “cliffs,” where if you take one extra step, and work 30 hours [instead of 29], the cost goes way up at the margin. Those would get eliminated, and would give businesses more flexibility, and would seemingly help workers at the same time who might want more hours.”

Families could switch jobs without worrying about what they would do during a probationary period at their new job before their health benefits kick in, and people with chronic medical conditions wouldn’t have to spend hours a day on the phone haggling with their health insurance providers to get essential services covered by them. From a cost perspective, yes, a single-payer system is cheaper than what we operate today. But from a time-saved perspective, from worrying-about-money-perspective, and from a can-I-take-my-kid-to-the-pediatrician? perspective, this works better. The time spent poring over confusing health care documents? Gone. Deductibles? Gone. What’s simpler is simpler — and for businesses and families, a seamless single-payer-system would lessen a lot of headaches and prevent a lot of pain.

Majority of U.S. doctors believe ACA has improved access to care

Sixty percent of U.S. physicians believe that the Affordable Care Act (ACA) has improved access to care and insurance after five years of implementation, according to a report published in the September issue of Health Affairs.

Lindsay Riordan, from the Mayo Clinic Alix School of Medicine in Rochester, Minnesota, and colleagues readministered elements of a previous survey to U.S. physicians to examine how their opinions of the ACA may have changed during the five-year implementation period (2012 to 2017). Responses were compared across surveys. A total of 489 physicians responded to the 2017 survey.

The researchers found that 60 percent of respondents believed that the ACA had improved access to care and insurance, but 43 percent felt that it had reduced coverage affordability. Despite reporting perceived worsening in several practice conditions, in 2017, more physicians agreed that the ACA “would turn the United States health care in the right direction” compared with 2012 (53 versus 42 percent). In the 2017 results, only political party affiliation was a significant predictor of support for the ACA after adjustment for potential confounding variables.

“A slight majority of U.S. physicians, after experiencing the ACA’s implementation, believed that it is a net positive for U.S. health care,” the authors write. “Their favorable impressions increased, despite their reports of declining affordability of insurance, increased administrative burdens, and other challenges they and their patients faced.”

And remember my suggestion was to improve the failures in the Affordable Care Act/Obamacare instead of this Medicare for All solution which is so short-sighted if anybody out there is on Medicare realizes….and it is not FREE!!

Walmart, CVS, Walgreen health clinics can fill a need, but there’s a hitch: Dr. Marc Siegel

Matthew Wisner reported that Walmart is opening its first health clinic in Georgia with plans to offer everything from shots to X-rays, dental and even eye care.

“You go to Walmart and you’re going to be able to get psychotherapy now. Labs, X-rays as you mentioned, immunizations, medications, there are nurses there, doctors there. They’re opening up in Texas, Georgia, and South Carolina,” Fox News medical correspondent Dr. Marc Siegel told the FOX Business Network’s “Varney & Co.”

According to Siegel, Walmart is trying to compete against the big pharmacy chains heading in the same direction.

“It’s also to compete with CVS/Aetna right, who is going to be opening 1,500 of these locations around the country. And, Walgreens as well, with Humana and United Healthcare. So all of these big pharmacy chains are getting into the stand-alone health-care model,” Siegel said.

Siegel says these types of clinics will offer access to health care that some consumers may not have, but he said there is a downside.

“But what happens to the results? Where is the follow-up? I don’t really want a Walmart doing all of the, or CVS, or Walgreens doing all of the follow-ups. I’m worried about someone coming in for one-stop shopping and not having follow up,” explained Siegel.

Lindsay Riordan, from the Mayo Clinic Alix School of Medicine in Rochester, Minnesota, and colleagues readministered elements of a previous survey to U.S. physicians to examine how their opinions of the ACA may have changed during the five-year implementation period (2012 to 2017). Responses were compared across surveys. A total of 489 physicians responded to the 2017 survey.

The researchers found that 60 percent of respondents believed that the ACA had improved access to care and insurance, but 43 percent felt that it had reduced coverage affordability. Despite reporting perceived worsening in several practice conditions, in 2017, more physicians agreed that the ACA “would turn the United States health care in the right direction” compared with 2012 (53 versus 42 percent). In the 2017 results, only political party affiliation was a significant predictor of support for the ACA after adjustment for potential confounding variables.

“A slight majority of U.S. physicians, after experiencing the ACA’s implementation, believed that it is a net positive for U.S. health care,” the authors write. “Their favorable impressions increased, despite their reports of declining affordability of insurance, increased administrative burdens, and other challenges they and their patients faced.”

Opinion: The U.S. can slash health-care costs 75% with 2 fundamental changes — and without ‘Medicare for All’. Dr. Ben Carson suggested using HSA’s to solve the health care problem and this article looks at funding the HSA deductible, as Indiana and Whole Foods do, and put real prices on everything

Sean Masaki Flynn noted that as the Democratic presidential candidates argue about “Medicare for All” versus a “public option,” two simple policy changes could slash U.S. health-care costs by 75% while increasing access and improving the quality of care.

These policies have been proven to work by ingenious companies like Whole Foods and innovative governments like the state of Indiana and Singapore. If they were rolled out nationally, the United States would save $2.4 trillion per year across individuals, businesses, and the government.

The first policy—price tags—is a necessary prerequisite for competition and efficiency. Under our current system, it’s nearly impossible for people with health insurance to find out in advance what anything covered by their insurance will end up costing. Patients have no way to comparison shop for procedures covered by insurance, and providers are under little pressure to lower costs.

By contrast, there is intense competition among the providers of medical services like LASIK eye surgery that aren’t covered by health insurance. For those procedures, providers must compete for market share and profits by figuring out ways to improve efficiency and lower prices. They must also advertise to get customers in the door and must ensure high quality to generate customer loyalty and benefit from word of mouth.

That’s why the price of LASIK eye surgery, as just one example, has fallen so dramatically even as quality has soared. Adjusted for inflation, LASIK cost nearly $4,000 per eye when it made its debut in the 1990s. These days, the average price is around $2,000 per eye and you can get it done for as little as $1,000 on sale.

By contrast, ask yourself what a colonoscopy or knee replacement will cost you. There’s no way to tell.

Price tags also insure that everybody pays the same amount. We currently have a health-care system in which providers charge patients wildly different prices depending on their insurance. That injustice will end if we insist on legally mandated price tags and require that every patient be charged at the same price.

As a side benefit, we will also see massively lower administrative costs. They are currently extremely high because once a doctor submits a bill to an insurance company, the insurance company works hard to deny or discount the claim. Thus begins a hideously costly and drawn-out negotiation that eventually yields the dollar amount that the doctor will get reimbursed. If you have price tags for every procedure and require that every patient be charged the same price, all of that bickering and chicanery goes away. As does the need for gargantuan bureaucracies to process claims.

What happened in Indiana?

The second policy—deductible security—pairs an insurance policy that has an annual deductible with a health savings account (HSA) that the policy’s sponsor funds each year with an amount equal to the annual deductible.

The policy’s sponsor can be either a private employer like Whole Foods (now part of Amazon.AMZN, -0.39%), which has been doing this since 2002 or a government entity like the state of Indiana, which has been offering deductible security to its employees since 2007.

While Indiana offers its workers a variety of health-care plans, the vast majority opt for the deductible security plan, under which the state covers the premium and then gifts $2,850 into each employee’s HSA every year.

Since that amount is equal to the annual deductible, participants have money to pay for out-of-pocket expenses. But the annual gifts do more than ensure that participants are financially secure; they give people skin in the game. Participants spend prudently because they know that any unspent HSA balances are theirs to keep. The result? Massively lower health-care spending without any decrement to health outcomes.

We know this because Indiana Gov. Mitch Daniels ordered a study that tracked health-care spending and outcomes for state employees during the 2007-to-2009 period when deductible security was first offered. Employees choosing this plan were, for example, 67% less likely to go to high-cost emergency rooms (rather than low-cost urgent care centers.) They also spent $18 less per prescription because they were vastly more likely to opt for generic equivalents rather than brand-name medicines.

Those behavioral changes resulted in 35% lower health-care spending than when the same employees were enrolled in traditional health insurance. Even better, the study found that employees enrolled in the deductible security plan were going in for mammograms, annual check-ups, and other forms of preventive medicine at the same rate as when they were enrolled in traditional insurance. Thus, these cost savings are real and not due to people delaying necessary care in order to hoard their HSA balances.

By contrast, the single-payer “Medicare for All” proposal that is being pushed by Bernie Sanders and Kamala Harris would create a health-care system in which consumers never have skin in the game and in which prices are hidden for every procedure.

That lack of skin in the game will generate an expenditure explosion. We know this because when Oregon randomized 10,000 previously uninsured people into single-payer health insurance starting in 2008, the recipients’ annual health-care spending jumped 36% without any statistically significant improvements in health outcomes.

Look at Singapore

By contrast, if we were to require price tags in addition to deductible security, the combined savings would amount to about 75% of what we are paying now for health care.

We know this to be true because while price tags and deductible security were invented in the United States, only one country has had the good sense to roll them out nationwide. By doing so, Singapore is able to deliver universal coverage and the best health outcomes in the world while spending 77% less per capita than the United States and about 60% less per capita than the United Kingdom, Canada, Japan, and other advanced industrial economies.

Providers post prices in Singapore, and people have plenty of money in their HSA balances to cover out-of-pocket expenses. As in the United States, regulators set coverage standards for private insurance companies, which then accept premiums and pay for costs in excess of the annual deductible. The government also directly pays for health care for the indigent.

The result is a system in which government spending constitutes about half of all health-care spending, as is the case in the United States. But because prices are so much lower, the Singapore government spends only about 2.4% of GDP on health care. By contrast, government health-care spending in the United States runs at 8% of GDP.

With Singapore’s citizenry empowered by deductible security and price tags, competition has worked its magic, forcing providers to constantly figure out ways to lower costs and improve quality. The result is not only 77% less spending than the United States but also, as Bloomberg Businessweek reports, one of the healthiest populations in the world.

If we are going to be serious about squashing health-care costs and improving the quality of care, we need to foster intense competition among health-care providers to win business from consumers who are informed, empowered and protected from financial surprises. Price tags and deductible security are the only policies that accomplish all of these goals.

I hope that politicians on both sides of the aisle will get behind these proven solutions. But realize that all these programs are missing a number of important parts of the equation to make the programs work: tort reform, the cost of medical education and the cost of drugs. These issues need to be included in the final solution and the eventual program. Washington should not be a place where good ideas go to die.

Poll: Dems more likely to support the ​candidate who backs Medicare for All over fixing Obamacare, Maybe and then there is Biden!

69477871_2236925356437111_1822674667475828736_nAitlin Oprysko noted that as the Democratic presidential field continues to grapple with plans to address health care, a significant majority of Democratic voters are more likely to back a 2020 primary candidate who supports “Medicare for All” than building on the Affordable Care Act, a new poll found.

According to the POLITICO/Morning Consult poll out Wednesday, 65 percent of Democratic primary voters would be more likely to support a candidate who wants to institute a single-payer health care system like Medicare for All; 13 percent said they’d be less likely to back a candidate based on that support.

While the Democratic base has essentially demanded that it’s White House hopefuls offer up a plan for universal health care, the party has devolved into infighting over the nuances of such plans, centering almost entirely on the role of private insurers in the health care market.

“Democrats are increasingly more inclined to back a 2020 candidate who supports Medicare for All versus revamping Obamacare,” said Tyler Sinclair, Morning Consult’s vice president. “In January, 57 percent of Democrats said they would be more likely to vote for a candidate who backs a Medicare for All health system over expanding the Affordable Care Act. That number has now risen to 65 percent.”

The issue has been one of the more contentious policy divides rippling through the extensive primary field. White House hopefuls like former Vice President Joe Biden, former Rep. John Delaney, and Sen. Michael Bennet have railed against the idea, arguing instead for building on Obamacare.

Biden’s front-runner status thus far has come close to being threatened by only Sens. Bernie Sanders and Elizabeth Warren, two of the most vocal proponents of Medicare for All, while some of the idea’s most vocal detractors have failed to gain traction in the race or have already dropped out.

But Biden this week made his most forceful case yet against scrapping one of the signature achievements of his tenure as vice president, dropping a one-minute ad in which he explains that health care is “deeply personal” to him.

“Obamacare is personal to me,” he says at the end of the spot, in which he invokes the unexpected death of his first wife and daughter and the cancer fight of his late son. “When I see the president try to tear it down, and others proposing to replace it and start over, that’s personal to me, too.”

Meanwhile, Sen. Kamala Harris’ faltering in recent polls has coincided with greater scrutiny and wavering when it comes to the role of private insurers in a potential Harris administration. Her plan has drawn criticism from both ends of the spectrum even as it’s been praised by health policy experts and former Obama administration officials.

On the left flank, Sanders and Warren have defended the proposal in the face of criticism from the center lane of the primary, and Sanders’ campaign has aggressively seized on Harris’ muddled messaging.

Overall, 53 percent of voters support Medicare for All, though fewer — 45 percent — say a candidate’s support for Medicare for All would make them more likely to vote for that candidate in a general election over one who would prioritize improving on Obamacare. The survey suggests a level of public support for single-payer health care that could take some sting out of Republicans’ plans to make Medicare for All a four-letter word they can wield against Democrats up and down the ballot in 2020.

The POLITICO/Morning Consult survey was conducted online Aug. 23-25 among a national sample of 1,987 registered voters, including 768 Democratic voters. Results from the full survey have a margin of error of plus or minus 2 points.

Morning Consult is a nonpartisan media and technology company that provides data-driven research and insights on politics, policy and business strategy. But here is a slightly different view on the desires of those Democrats!

Democrats Want Medicare for All … or Maybe Not

Yuval Rosenberg of the Fiscal Times reported that a new Morning Consult/Politico poll finds support among Democrats rising for candidates that favor Medicare for All overbuilding on the Affordable Care Act. The survey found a 52-point margin of support — the share of those who said they would be more likely to back a candidate minus the share who said they would be less likely — for a candidate that backs Medicare for All, up from 35 points in January.

The poll surveyed 1,987 registered voters, including 768 Democratic voters, and had an overall margin of error of 2 percentage points. The Democratic subsample has a margin of error of 4 percentage points.

The Morning Consult results are similar to the findings of a new Monmouth University poll in which 58% of Democratic voters say it is very important to them that the party nominate someone who supports “Medicare for All.” But the poll also found that most voters, 53%, say they want a system that allows people to opt into Medicare while maintaining a private insurance market — what policy experts call a “public option.” Just 22% say they want to switch to a system where a government-run health plan replaces private insurance.

That may help explain why the Morning Consult poll finds that former vice president Joe Biden, who favors expanding the ACA by adding a public option, holds a 13-point advantage over Sen. Bernie Sanders (I-Vt.), who has championed Medicare for All.

Another explanation: Voters have other issues on their minds. Leslie Dach, campaign chair for health care advocacy group Protect Our Care, told Morning Consult that the latest poll results showing continued support for Biden demonstrate that Democratic voters are driven by a desire to remove President Trump from the office more than by questions about health care. And on the issue of health care, they’re more responsive to pocketbook issues like drug costs and protections for people with pre-existing conditions than to broader questions about the future structure of the U.S. health care system.

Bernie Sanders calls for eliminating all medical debt at the South Carolina event

Bernie Sanders teases plan to eliminate all medical debt and how ridiculous it sounds and really is!!

Andrew Craft or Fox News reported that the Democratic presidential candidate Sen. Bernie Sanders, I-Vt., told an audience in South Carolina Friday that he is working on legislation that would “eliminate medical debt in this country.”

Sanders made the remark during a question-and-answer period following a town hall meeting in Florence on “Medicare-for-All.” A female attendee explained to Sanders that she doesn’t make enough money to qualify for ObamaCare and has a large amount of medical debt not covered by insurance.

When the woman asked Sanders if he had a plan for that, the self-described democratic socialist told her: “In another piece of legislation that we’re offering, we’re gonna eliminate medical debt in this country.”

The Sanders campaign confirmed to Fox News that the proposal was new, but details were scant.

“We are introducing legislation that would end all medical debt in this country,” Sanders told reporters as he departed the town hall. “The bottom line is it is an insane and cruel system, which says to people that they have to go deeply into debt or go bankrupt because of what? Because they came down with cancer or they came down with heart disease or they came down with Alzheimer’s, or whatever …

“In the midst of a dysfunctional healthcare system, we have to say to people that you cannot go bankrupt or end up in financial duress,” Sanders added. “That is cruel and something we’ve gotta handle. This is something that we’re working on and that we will introduce.”

Sanders has long touted his “Medicare-for-All” proposal, which would replace job-based and individual private health insurance with a government-run plan that guarantees coverage for all with no premiums, deductibles and only minimal copays for certain services. Health care has become a key issue in South Carolina, which is among the Republican-led states that turned down Medicaid expansion under the Affordable Care Act.

Sanders’ legislation does not specify new revenues, instead of providing a separate list of “options” that include higher taxes on the wealthy, corporations and employers while promising the middle class will be better off.

“You’re going to be paying more in taxes,” Sanders said Friday to a man asking how he’d benefit from Medicare for All if his employer currently pays for most of his premiums. “But at the end of the day, you’re going to be paying less for health care than you are right now. It will be comprehensive.”

The healthcare industry has become a favorite whipping boy for Sanders, who told his audience Friday: “Thirty years from now your kids and your grandchildren will be asking you was it really true? That there were people in America who could not go to the doctor when they wanted to? Was it really true that people went bankrupt because they could not pay their healthcare bills? And you will have to tell them, ‘Yes, it was.’ But together we are going to end that obscenity and we’re going to end it in the next few years.”

The new proposal is not the only debt that Sanders has called for canceling. He has repeatedly called for the elimination of $1.6 trillion in student loan debt as well and calling for public college and universities to be tuition-free.

According to the RealClearPolitics polling average, Sanders is the second choice among Democrats nationwide, garnering 17.1 percent of the vote. Former Vice President Joe Biden holds a comfortable lead with 28.9 percent support, while Elizabeth Warren is narrowly behind Sanders in third place at 16.5 percent support.

Sanders: Medicare for All means more taxes, better coverage

Meg Kinnard of the Associated Press reported that health care was the focus of Democratic presidential hopeful Bernie Sanders’ second day of campaigning in pivotal early-voting South Carolina, where lack of Medicaid expansion has left thousands unable to obtain health coverage.

The Vermont senator focused on “Medicare for All,” his signature proposal replacing job-based and individual private health insurance with a government-run plan that guarantees coverage for all with no premiums, deductibles and only minimal copays for certain services.

“While this health care system is not working for working families, it is working for one group of people,” Sanders told a crowd of 300 on Friday. “The function of a rational health care system is not to make billions for insurance companies and drug companies. It is to provide health care to every man woman and child as a human right.”

Health care and how to reform the nation’s system is a critical debate among the candidates vying for the Democratic nomination. It’s under intense focus in states like South Carolina, home to the first-in-the-South 2020 primary, which is among the Republican-led states that turned down Medicaid expansion under the Affordable Care Act.

As a result of that decision, according to healthinsurance.org, a health insurance industry watchdog, about 92,000 South Carolinians are in the “coverage gap,” without access to insurance. This group of mostly low-income residents doesn’t qualify for subsidies on the exchange and is heavily reliant on emergency rooms and community clinics for care.

The lack of expansion has also had institutional ramifications, leading to the closures of hospitals in rural areas, tasked with serving a wide-reaching population and heavily reliant on Medicaid funds. According to the Sheps Center for Health Services Research at the University of North Carolina, 113 rural hospitals have closed since January 2010. Four of those facilities were in South Carolina.

While the overall notion of “Medicare for All” remains popular, some recent polling has shown softening support for the single-payer system, with hesitation at the idea of relinquishing private coverage altogether. Under Sanders’ legislation, it would be unlawful for insurers or employers to offer coverage for benefits provided by the new government-run plan.

Nationwide, 55% of Democrats and independent voters who lean Democratic said in a poll last month they’d prefer building on President Barack Obama’s Affordable Care Act instead of replacing it with Medicare for All. The survey by the nonpartisan Kaiser Family Foundation found that 39% would prefer Medicare for All. Majorities of liberals and moderates concurred.

Sanders’ legislation does not specify new revenues, instead of providing a separate list of “options” that include higher taxes on the wealthy, corporations and employers while promising the middle class will be better off.

“You’re going to be paying more in taxes,” Sanders said Friday to a man asking how he’d benefit from Medicare for All if his employer currently pays for most of his premiums. “But at the end of the day, you’re going to be paying less for health care than you are right now. It will be comprehensive.”

Sanders tallied up other personal expenses that would go away under his plan, including co-pays and medication costs over a $200-per-year cap. Sanders said he was also working on a proposal to eliminate medical debt, which he called the leading cause of consumer bankruptcy.

His campaign provided more details on Saturday, saying the plan would cancel an existing $81 billion in existing, past-due medical debt, with the federal government negotiating and paying off bills in collections. Sanders is proposing changes to a 2005 bankruptcy bill, which he blames for further hampering Americans’ abilities to regain their financial footing.

In early states including South Carolina, some voters continue to voice confusion as to exactly what various candidates in the vast Democratic field mean when they advocate for pieces of a Medicare for All plan. California Sen. Kamala Harris’ new plan would preserve a role for private insurance. New Jersey Sen. Cory Booker is open to step-by-step approaches.

Others including former Vice President Joe Biden have been blunt in criticizing the government-run system envisioned by Sanders.

Biden health plan aims far beyond the legacy of ‘Obamacare’

Ricardo Alonso-Zaldivar of the Associated Press noted that wrapping himself in the legacy of “Obamacare,” Joe Biden is offering restless Democrats a health care proposal that goes far beyond it, calling for a government plan almost anybody can join but stopping short of a total system remake. But why does he propose a health care plan, Obamacare, that he was sooooo proud of??

Recent polls show softening support for the full government-run system championed by Sen. Bernie Sanders, and Biden is pitching his approach in a new ad aimed at Democrats in Iowa. His “public option” would give virtually everyone the choice of a government plan like Medicare, as an alternative to private coverage, not a substitute.

“The fact of the matter is health care is personal to me,” Biden says in the ad, recalling his own family experiences with illness and loss. “Obamacare is personal to me. When I see the president try to tear it down and others propose to replace it and start over, that’s personal to me, too. We’ve got to build on what we did because every American deserves affordable health care.”

Biden’s health care gambit puts him somewhere center-left on the spectrum of ideas from Democratic presidential candidates.

Sanders and Massachusetts Sen. Elizabeth Warren are solidly behind “Medicare for All,” the government-run “single-payer” approach. California Sen. Kamala Harris is offering to retain private plans within a government system. Colorado Sen. Michael Bennet who is proposing a limited public option focused on areas with little insurer competition, calls it “the most effective way to cover everyone and lower costs.”

Sanders, in a veiled swipe, has accused Biden of “tinkering around the edges.” But Biden’s more ambitious public option would be open to people around the country, including those with employer coverage. That would set up a competition between a government plan and the mainstay of private coverage in the U.S.

“The Biden plan is modest in comparison to ‘Medicare for All,’ but it is by no means modest by historical standards,” said Larry Levitt of the nonpartisan Kaiser Family Foundation. “It goes well beyond even the most progressive proposals during the Affordable Care Act debate. It does show how the health care debate has shifted when this is considered a moderate proposal.”

Here’s a look:

THE BLUEPRINT

President Barack Obama’s former vice president builds on the ACA to address what former Democratic Senate aide John McDonough calls its “shortcomings, weaknesses, and pain points.”

Biden would provide more generous subsidies for “Obamacare’s” private policies, also lowering deductibles and copays. He’d let solidly middle-class people qualify for help paying their premiums, responding to complaints that they’re now priced out.

That’s for starters.

Biden adds his public option plan, something Obama couldn’t get through Congress when Democrats controlled it.

Biden’s version would be modeled on Medicare and open to just about any U.S. citizen or legal resident. One of its goals would be to provide free coverage for low-income people in states that have refused the ACA’s Medicaid expansion, including Texas and Florida.

And in a landmark change, Biden would open the public plan to people with access to job-based insurance if that’s what they want. Most workers don’t have such a choice now.

Campaign policy director Stef Feldman said Biden feels strongly that people with workplace coverage should have another choice.

It’s unclear how many people would switch from employer coverage to the public option, but the Kaiser Foundation’s Levitt notes, “It would be a voluntary shift on the part of workers.”

Under the plan, people who qualify for ACA subsidies would be able to use that money for public option premiums. “The public option and private insurance will hold each other accountable,” Feldman said.

But even as it gives consumers more choices, the public plan could undermine employer coverage, particularly if it draws away younger and healthier workers.

A coalition of insurers, hospitals and drug makers formed to fight “Medicare for All” is trying to derail the public option as well.

“It would be a dramatic policy change,” said McDonough, who teaches at the Harvard T.H. Chan School of Public Health. The prospect of payments pegged to Medicare’s lower rates “is already alarming the provider community.”

Another part of Biden’s plan would tackle the high cost of prescription drugs, an issue that President Donald Trump has sought to address.

His most significant idea would limit launch prices for cutting-edge drugs that can cost hundreds of thousands of dollars. He’d also hold pharmaceutical price increases to the inflation rate, allow Medicare to negotiate with drugmakers, and clear the way for patients to import drugs from abroad.

Overall, Biden’s campaign estimates his plan would cover 97% of those eligible.

He’d also restore Obama’s unpopular fines on people who go without health insurance, which were repealed by Congress.

THE POOR AND THE MIDDLE CLASS

“Obamacare” and the Republican backlash against it had unintended consequences both for low-income uninsured people and for middle-class consumers who once purchased their own policies but can no longer afford the high premiums.

Many GOP-led states have turned down the ACA’s Medicaid expansion. Nationally, nearly 5 million low-income people would gain coverage if all states expanded Medicaid. Biden would enroll them in the public option at no cost to them or their state.

That might well upset leaders in mostly Democratic states that embraced the Medicaid expansion and are helping pay for it. But campaign policy director Feldman says Biden “is done with” letting state politics interfere with coverage.

For middle-class people who buy their own health insurance, Biden would lift the ACA’s income limit on subsidies to help pay premiums.

ACA critic Robert Laszewski calls that a welcome fix. “Biden has done what needed to be done,” said Laszewski, a consultant and blogger. “The fundamental problem is that the middle class can’t afford the Obamacare policy.”

THE COST

After expected savings on prescription drugs and elsewhere, the Biden campaign estimates the plan’s net cost at $750 billion over 10 years, paid for by raising taxes on upper-income people and on investment income.

By comparison, “Medicare for All” is projected to cost $30 trillion to $40 trillion over 10 years.

While Biden’s plan clearly would cost less, health economist Gail Wilensky says she’s skeptical of the campaign number.

“Campaigns want to underestimate the cost and overestimate the benefits and make the financing sound easier than it will be,” said Wilensky, a longtime Republican adviser.

And on and on the discussion goes as to what the eventual Democratic presidential candidate will actually stick with and possibly what we all may have to live with. More on this discussion in the many weeks before and after the 2020 election.

Hoping that you all are enjoying your Labor Day weekend and the “end” of summer!

Fact Check: Are there ‘more gun deaths by far’ in America than any other country? And what is the GOP going to do about IT?

Screen Shot 2019-08-26 at 9.19.29 PMThis is another very long post but gun violence and the solutions need to be center stage going forward. We in health care see the results of gun violence every day in our hospitals, ERs, and offices. Texan Beto O’Rourke joined nine other Democrats on stage in Detroit on Tuesday for the second round of debates in the Democratic presidential primary contest. All of the candidates made questionable statements — take a look at some fact-checking from the night — including O’Rourke, who was asked to respond to a comment about gun violence from Montana Gov. Steve Bullock.

Bullock said that Washington, D.C., “is captured by dark money” and political influence from the likes of the NRA and Koch Industries, making it hard for lawmakers to tackle issues like gun safety.

“That’s the way we’re actually going to make a change on this, Don, is by changing that system,” Bullock said, addressing moderator Don Lemon of CNN. “And most of the things that folks are talking about on this stage we’re not going to address until we kick dark money and the post-Citizens United corporate spending out of these elections.”

Lemon asked O’Rourke to respond to Bullock’s point.

“How else can we explain that we lose nearly 40,000 people in this country to gun violence, a number that no other country comes even close to, that we know what all the solutions are, and yet nothing has changed?” O’Rourke said. “It is because, in this country, money buys influence, access and, increasingly, outcomes.”

We assumed O’Rourke was talking about the number of gun deaths in the United States in the past year, a figure supported by federal data. But is O’Rourke right that no other country comes close to the number of deaths by gun violence in the United States? We took a look.

By Chris Nichols on Tuesday, August 6th, 2019 at 5:32 p.m.

Following the recent mass shootings in Gilroy, California and El Paso, Texas, and just hours before a separate mass shooting in Dayton, Ohio, California Democratic Sen. Dianne Feinstein made a sweeping statement about the number of guns and gun deaths in America.

“There are more guns in this country than people and more per capita than any other country in the world. And there are more gun deaths by far,” Feinstein, a strong advocate for gun control, said on Twitter on Aug. 3, 2019. “I continue to hope that opponents of commonsense gun reform laws will come to their senses and join the effort to save lives.”

Sen. Dianne Feinstein, D-CA, posted this tweet on Aug. 3, 2019.

As of early this week, 22 people were killed in the El Paso shooting, nine in Dayton and three in Gilroy. The suspected gunmen in Dayton and Gilroy also died.

We examined each part of Feinstein’s statement but found we couldn’t place a Truth-O-Meter rating on the first two parts because there’s no official count on the number of guns in America and there are competing estimates on how many exist.

We did place a rating on the last portion about America having “more gun deaths by far” than any other country.

We’ll provide analysis on each piece of Feinstein’s statement below.

Feinstein on guns

First, here’s some background on the senator. In 1994, she authored the Federal Assault Weapons Ban, which was signed by President Bill Clinton. It prohibited the manufacture of 19 specific kinds of military-style, semi-automatic firearms, often called assault weapons.

It also banned the manufacture and sale of gun magazines that hold more than 10 bullets.

The bill expired in 2004 after efforts to extend it failed in Congress.

Its restrictions did not apply to any semi-automatic weapons or magazines made before the ban’s effective date: Sept. 13, 1994.

Feinstein has remained an advocate for gun control. In February of this year, she introduced a bill that would pay for states to create their own extreme-risk protection laws, also known as red flag laws.

Those would allow family members to petition for a court order to “grant law enforcement the authority to temporarily take weapons from dangerous individuals who present a threat to themselves or others,” according to Feinstein’s office.

California, Maryland, and Florida have already enacted similar laws.

“There are more guns in this country than people” 

There are no official count of the number of firearms in the United States, only widely varying estimates, as PolitiFact has reported in the past.

As the Pew Research Center has observed: “Gun ownership is one of the hardest things for researchers to pin down.”

We found estimates as low as 265 million civilian guns in the U.S. in January 2015 — to as high as 393 million in a report last year.

Researchers say estimates can include guns that no longer work, leading to an overcount. Meanwhile, some survey respondents will understate the number of guns they own, leading to an undercount.

With no definitive tally, we decided not to place a rating on this portion of Feinstein’s statement.

“More (guns) per capita than any other country in the world”

This second part of the claim is generally on the right track, whether looking at the high estimates for guns in America or the lower ones. But again it relies on a topic for which there’s no settled data.

Taking the estimate of 393 million civilian firearms, there would be 120.5 guns for every 100 residents in the United States. As The Washington Post reported, that’s twice the per capita rate of the next-highest nation, Yemen, with just 52.8 guns per 100 residents.

Using the lower estimate of 265 million guns in 2015 would still produce about 83 guns for every 100 Americans that year.

While this part of Feinstein’s claim is likely more accurate, the per capita rate doesn’t mean all Americans own guns. Instead, gun ownership is concentrated among a minority of the US population — as surveys from the Pew Research Center and General Social Survey suggest, according to the Post.

“More gun deaths by far” in the United States?

This part of Feinstein’s statement is not supported. We found the United States experiences more firearm injury deaths than other countries of similar socioeconomic standing. But that’s not what Feinstein claimed. She suggested it had “more gun deaths by far” than any other country.

In 2017, Brazil had the most overall gun deaths of any country at 48,493, including homicides, suicides and unintentional gun deaths, according to a June 2018 report by the University of Washington’s Institute for Health Metrics and Evaluation.

The United States had the second most overall gun deaths at 40,229, though it had the highest suicide by a gun total of any nation, at nearly 25,000. Data from the report showed Brazil had the most overall gun deaths at least from 2015 through 2017.

“Yes, Brazil is highest by number” for overall gun deaths, the study’s author, Professor Moshen Naghavi, said by email.

“We believe 2018 and 2019 will be higher,” Naghavi said in a follow-up phone interview, citing decisions made by Brazil’s new president to make firearms more accessible.

Feinstein’s office did not respond to our request for information supporting this portion of her statement.

PolitiFact Texas fact-checked a similar claim last week by former Rep. Beto O’Rourke and rated it Mostly False. O’Rourke said at the Democratic presidential debate in Detroit that “we lose nearly 40,000 people in this country to gun violence, a number that no other country comes even close to.” It cited the University of Washington study and noted that more than a dozen countries had more firearm deaths per capita than the United States in 2016.

Our rating

Sen. Dianne Feinstein claimed, “There are more guns in this country than people and more per capita than any other country in the world. And there are more gun deaths by far.”

We could not place a rating on the first two parts because there are no official count of guns in America, only widely varying estimates.

The last part of her statement, however, is not supported. A recent study showed Brazil, not the United States, had the most overall gun deaths of any country over the last several years. America, however, had the highest total of suicides by firearm of any nation.

In the end, she was wrong that there are “more gun deaths by far” in the United States than any other country in the world.  Here are two charts/tables with data.

Screen Shot 2019-08-25 at 12.25.22 AM

Screen Shot 2019-08-25 at 12.26.10 AM

We rate that portion of her claim False.

FALSE – The statement is not accurate.

America’s gun culture in charts

Two mass shootings within 24 hours, leaving 31 people dead, has once again brought the spotlight on gun ownership in the United States.

An attack on a Walmart store in El Paso, Texas on Saturday left 20 dead, while nine died in a shooting in Dayton, Ohio on Sunday.

But where does America stand on the right to bear arms and gun control?

What do young people think about gun control?

Screen Shot 2019-08-25 at 9.19.30 PM

When looking at the period before the Parkland school shooting in 2018, it is interesting to track how young people have felt about gun control.

Support for gun control over the protection of gun rights in America is highest among 18 to 29-year-olds, according to a study by the Pew Research Centre, with a spike after the Orlando nightclub shooting in 2016. The overall trend though suggests a slight decrease in support for gun control over gun rights since 2000.

Pew found that one-third of over-50s said they owned a gun. The rate of gun ownership was lower for younger adults – about 28%. White men are especially likely to own a gun.

How does the US compare with other countries?

I included two charts in the previous discussion and here are two more.

About 40% of Americans say they own a gun or live in a household with one, according to a 2017 survey, and the rate of murder or manslaughter by firearm is the highest in the developed world. There were almost 11,000 deaths as a result of murder or manslaughter involving a firearm in 2017.

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Homicides are taken here to include murder and manslaughter. The FBI separates statistics for what it calls justifiable homicide, which includes the killing of a criminal by a police officer or private citizen in certain circumstances, which are not included.

In about 13% of cases, the FBI does not have data on the weapon used. By removing these cases from the overall total of gun deaths in the US, the proportion of gun-related killings rises to 73% of homicides.

Who owns the world’s guns?

While it is difficult to know exactly how many guns civilians own around the world, by every estimate the US with more than 390 million is far out in front.

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Switzerland and Finland are two of the European countries with the most guns per person – they both have compulsory military service for all men over the age of 18. The Finnish interior ministry says about 60% of gun permits are granted for hunting – a popular pastime in Finland. Cyprus and Yemen also have military service.

How do US gun deaths break down?

There have been more than 110 mass shootings in the US since 1982, according to the investigative magazine Mother Jones.

Up until 2012, a mass shooting was defined as when an attacker had killed four or more victims in an indiscriminate rampage – and since 2013 the figures include attacks with three or more victims. The shootings do not include killings related to other crimes such as armed robbery or gang violence.

The overall number of people killed in mass shootings each year represents only a tiny percentage of the total number.

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Figures from the Centers for Disease Control and Prevention show there were a total of more than 38,600 deaths from guns in 2016 – of which more than 22,900 were suicides. Suicide by firearm accounts for almost half of all suicides in the US, according to the CDC.

A 2016 study published in the American Journal of Public Health found there was a strong relationship between higher levels of gun ownership in a state and higher firearm suicide rates for both men and women.

Attacks in the US become deadlier

The Las Vegas attack in 2017 was the worst in recent US history – and eight of the shootings with the highest number of casualties happened within the past 10 years.

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What types of guns kill Americans?

Military-style assault-style weapons have been blamed for some of the major mass shootings such as the attack in an Orlando nightclub and at the Sandy Hook School in Connecticut.

Dozens of rifles were recovered from the scene of the Las Vegas shooting, police reported.

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A few US states have banned assault-style weapons, which were totally restricted for a decade until 2004.

However, most murders caused by guns involve handguns, according to FBI data.

How much do guns cost to buy?

For those from countries where guns are not widely owned, it can be a surprise to discover that they are relatively cheap to purchase in the US.

Among the arsenal of weapons recovered from the hotel room of Las Vegas shooter, Stephen Paddock were handguns, which can cost from as little $200 (£151) – comparable to a Chromebook laptop.

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Assault-style rifles, also recovered from Paddock’s room, can cost from around $1,500 (£1,132).

In addition to the 23 weapons at the hotel, a further 19 were recovered from Paddock’s home. It is estimated that he may have spent more than $70,000 (£52,800) on firearms and accessories such as tripods, scopes, ammunition, and cartridges.

Who supports gun control?

US public opinion on the banning of handguns has changed dramatically over the last 60 years. Support has shifted over time and now a significant majority opposes a ban on handguns, according to polling by Gallup.

But a majority of Americans say they are dissatisfied with US gun laws and policies, and most of those who are unhappy want stricter legislation.

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Some states have taken steps to ban or strictly regulate ownership of assault weapons. Laws vary by state but California, for example, has banned around 75 types and models of an assault weapon.

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Some controls are widely supported by people across the political divide – such as restricting the sale of guns to people who are mentally ill, or on “watch” lists.

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But Republicans and Democrats are much more divided over other policy proposals, such as whether to allow ordinary citizens increased rights to carry concealed weapons – according to a survey from Pew Research Center.

Who opposes gun control?

The National Rifle Association (NRA) campaigns against all forms of gun control in the US and argues that more guns make the country safer.

It is among the most powerful special interest lobby groups in the US, with a substantial budget to influence members of Congress on gun policy.

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In total, about one in five US gun owners say they are members of the NRA – and it has especially widespread support from Republican-leaning gun owners, according to Pew Research.

In terms of lobbying to influence gun policy, the NRA’s spending jumped from about $3m per year to more than $5m in 2017.

The chart shows only the recorded contributions to lawmakers published by the Senate Office of Public Records.

The NRA spends millions more elsewhere, such as on supporting the election campaigns of political candidates who oppose gun controls.

GOP Waits to See if Trump Will Protect It From the NRA Before Moving on Gun Laws

Sam Brodey Noted that just over a week since mass shootings in El Paso, Texas, and Dayton, Ohio, Senate Republicans are waiting to see if President Trump walks away from the issue again or forces their hand before trying to do anything about potentially expanding background checks for gun purchases.

He’s walked away before. Following the Parkland school massacre last year, the president promised that he was “going to be very strong on background checks,” only to retreat after holding private meetings with National Rifle Association officials at the White House. The NRA, a key ally of Trump’s, has spent big money lobbying against background-checks expansion legislation, and last week reminded him of its staunch opposition.

After the latest shootings, Trump told reporters that there is great “appetite” on the Hill to finally get something done on background checks but his GOP allies in the Senate are holding off, unwilling to burn political capital with the gun lobby and conservative-base voters on the issue if Trump isn’t going to burn some of his.

However, the president’s prior inaction, and the media coverage he incurred for it, may force him to make at least a slightly harder run at background checks this time around, even if only in his messaging and bluster. Two people who’ve spoken to the president in recent days say that he has referenced, during conversations about how he could possibly bend the NRA to his will in this case, his annoyance at media coverage of his post-Parkland about-face that suggested he was all talk and no action on the issue, and easily controlled by the NRA. One of the sources noted that Trump’s aversion to being seen as “controlled” by anyone or any organization makes it much more likely that the president will dwell on the issue for longer than he did last year.

Trump’s influence could well make or break legislation, since Republicans are unlikely to support anything without his blessing but will be just as hesitant to immediately reject a bill he puts his full support behind.

“Many Hill Republicans are waiting to see what Trump will get behind,” said a Senate GOP aide. “He gives them political cover. I don’t think you’re going to see any one bill or one proposal get any momentum until the President publicly endorses it.”

Senate Majority Leader Mitch McConnell (R-KY) said on Thursday that he and the president are actively discussing possible avenues for gun legislation. “He’s anxious to get an outcome and so am I,” said McConnell on a radio show in Kentucky.

The GOP leader stressed that the president was open to a discussion on gun legislation, from background checks to “red flag” bills: “Those are two items that for sure will be front and center as we see what we can come together on and pass.”

A spokesman for McConnell declined to elaborate on the Senate leader’s conversations with the president.

Democrats aren’t holding their breath, given that McConnell won’t call the Senate back from its recess for gun bills and that Trump has backtracked before on the issue after outcry from pro-gun factions of his base.

Democratic aides have been mindful of Sean Hannity’s reaction to the background checks push, since Trump’s position has been known to change based on the broadcasts or private counsel of Hannity and other top Fox personalities.

White House aides are similarly waiting on Trump, and talking up how he’s also been reaching out across the aisle to find a potential solution, even if nobody knows what that would look like yet. “The president has been actively talking to Republicans and Democrats on the matter of background checks, and just being able to have meaningful, measurable reforms that don’t confiscate law-abiding citizens’ firearms without due process, but at the same time keep those firearms out of people who have a propensity toward violence,” Kellyanne Conway, Trump’s White House counselor, said on this week’s Fox News Sunday.

One of those Democratic politicians, Sen. Joe Manchin (D-WV), said in a call with reporters on Wednesday he had spoken to the president twice since the shootings in Dayton and El Paso and that he was “committed to getting something done.”

While “everything is on the table,” Manchin said, Trump’s sign-off on any plan will be key to getting it through the Senate. The proposal introduced by Sen. Pat Toomey (R-PA) and Manchin in the months after the massacre at Sandy Hook elementary made modest adjustments to background check system by extending checks to gun shows and internet sales, but exempted gun transactions between friends and family members. It also provided additional funding to states to put critical information into the National Instant Criminal Background Check System in order to prevent people who should not have guns from obtaining them, and created a commission to study the causes of gun violence.

It’s a bill that’s failed twice, once in 2013 and again after the mass shooting in a San Bernardino office park in 2015. Both times it drew very limited support from Republican senators.

Asked what had changed since the last time the bill failed on the Senate floor, Manchin said, “The political will wasn’t there.”

Manchin said he was told by some colleagues who opposed the bill that they really didn’t object to the substance of the bill but they weren’t convinced the “Obama administration wouldn’t go further [and try] taking more of their guns away from them.”

Manchin said he tried to explain that would be unconstitutional, but to no avail.

Some Trump allies say that this president, given his record and rhetoric, might have just enough credibility among Second Amendment enthusiasts to drag them along, if he so chooses.

“If only Nixon could go to China, then maybe only Trump can address the chasm between gun owners and those who want gun control,” Michael Caputo, a former Trump campaign adviser, told The Daily Beast. “He’s so strong on the Second Amendment he can truly do something to make a change when it comes to these mass shootings.”

Caputo, who in 2013 and 2014 advised Trump on pro-gun voters and the NRA when the celebrity businessman was weighing a run for New York governor, said that even years ago, “We talked about mass shootings and what that means to the United States, and the importance [to voters] of the Second Amendment, and I know the president has been thinking about this issue for a long time: How you balance gun rights versus gun atrocities.”

Trump’s former adviser added, “If the president pursues broader background checks… perhaps it’s because he knows that is something only he can do. He may lose the support of some of the most pro-gun members of his base, but the vast majority of us understand there are some reasonable measures to be taken.”

I will be very interested to see what happens in D.C. when Congress comes back from their vacation. Will they all together come up with realistic guns laws without the concern for the NRA? That includes the President and yes, both parties in both houses!

Firearm-Related Injury and Death in the United States: A Call to Action From the Nation’s Leading Physician and Public Health Professional Organizations; Politics and Solutions!

rifles364I have been so upset with the recent mass shootings and the lack of action to start the real discussion and solutions I thought that I would dedicate a few posts to this subject. The President and Congress had better get something done because the voters are pretty sick and tired of inaction and the GOP being afraid of the NRA. Get over it and do the right thing and come up solutions and more important, stop making it political!!!

Robert McLean, Patricia Harris, John Cullen, etc. of the AMA noted that shortly after the November publication of the American College of Physicians’ policy position paper on reducing firearm injury and death, the National Rifle Association tweeted:

Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.

Within hours, thousands of physicians responded, many using the hashtags #ThisIsOurLane and #ThisIsMyLane, and shared the many reasons why firearm injury and death is most certainly in our lane. Across the United States, physicians have daily, firsthand experience with the devastating consequences of firearm-related injury, disability, and death. We witness the impact of these events not only on our patients, but also on their families and communities. As physicians, we have a special responsibility and obligation to our patients to speak out on prevention of firearm-related injuries and deaths, just as we have spoken out on other critical public health issues. As a country, we must all work together to develop practical solutions to prevent injuries and save lives.

In 2015, several of our organizations joined the American Bar Association in a call to action to address firearm injury as a public health threat. This effort was subsequently endorsed by 52 organizations representing clinicians, consumers, families of firearm injury victims, researchers, public health professionals, and other health advocates. Four years later, firearm-related injury remains a problem of epidemic proportions in the United States, demanding immediate and sustained intervention. Since the 2015 call to action, there have been 18 firearm-related mass murders with 4 or more deaths in the United States, claiming a total of 288 lives and injuring 703 more.

With nearly 40 000 firearm-related deaths in 2017, the United States has reached a 20-year high according to the Centers for Disease Control and Prevention (CDC). We, the leadership of 6 of the nation’s largest physician professional societies, whose memberships include 731 000 U.S. physicians, reiterate our commitment to finding solutions and call for policies to reduce firearm injuries and deaths. The authors represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Surgeons, American Medical Association, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, joins these 6 physician organizations to articulate the principles and recommendations summarized herein. These recommendations stem largely from the individual positions previously approved by our organizations and ongoing collaborative discussion among our leaders.

Background

In 2017, a total of 39 773 people died in the United States as a result of firearm-related injury—23 854 (59.98%) were suicides, 14 542 (36.56%) were homicides, 553 (1.39%) were the result of legal intervention, 486 (1.22%) were subsequent to unintentional discharge of a firearm, and 338 (0.85%) were of undetermined origin. The population-adjusted rates of these deaths are among the highest worldwide and are by far the highest among high-income countries. Firearm-related deaths now exceed motor vehicle–related deaths in the United States. Further, estimates show that the number of nonfatal firearm injuries treated in emergency departments is almost double the number of deaths. Firearm-related injury and death also present substantial economic costs to our nation, with total societal cost estimated to be $229 billion in 2015.

While mass shootings account for a small proportion of the nearly 109 firearm-related deaths that occur daily in the United States, the escalating frequency of mass shootings and their toll on individuals, families, communities, and society make them a hot spot in this public health crisis. Mass shootings create a sense of vulnerability for everyone, that nowhere—no place of worship, no school, no store, no home, no public gathering place, no place of employment—is safe from becoming the venue of a mass shooting. Mass shootings have mental health consequences not only for victims, but for all in affected communities, including emergency responders. Studies also show that mass shootings are associated with increased fear and decreased perceptions of safety in indirectly exposed populations. Preventing the toll of mass firearm violence on the well-being of people in U.S. cities and towns demands the full resources of our health care community and our governments.

Our organizations support a multifaceted public health approach to prevention of firearm injury and death similar to approaches that have successfully reduced the ill effects of tobacco use, motor vehicle accidents, and unintentional poisoning. While we recognize the significant political and philosophical differences about firearm ownership and regulation in the United States, we are committed to reaching out to bridge these differences to improve the health and safety of our patients, their families, and communities, while respecting the U.S. Constitution.

A public health approach will enable the United States to address culture, firearm safety, and reasonable regulation consistent with the U.S. Constitution. Efforts to reduce firearm-related injury and death should focus on identifying individuals at heightened risk for violent acts against themselves or others. All health professionals should be trained to assess and respond to those individuals who may be at heightened risk of harming themselves or others.

Screening, diagnosis, and access to treatment for individuals with mental health and substance use disorders is critical, along with efforts to reduce the stigma of seeking this mental health care. While most individuals with mental health disorders do not pose a risk for harm to themselves or others, improved identification and access to care for persons with mental health disorders may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

In February 2019, 44 major medical and injury prevention organizations and the American Bar Association participated in a Medical Summit on Firearm Injury Prevention. This meeting focused on building consensus on the public health approach to this issue, highlighting the need for research, and developing injury prevention initiatives that the medical community could implement. Here we highlight specific policy recommendations that our 7 organizations believe can reduce firearm-related injury and death in the United States.

Background Checks for Firearm Purchases

Comprehensive criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, private sales, and transfers between individuals with limited exceptions should be required.

Current federal laws require background checks for purchases from retail firearm sellers (Federal Firearms License [FFL] holders); however, purchases from private sellers and transfer of firearms between private individuals do not require background checks. Approximately 40% of firearm transfers take place through means other than a licensed dealer; as a result, an estimated 6.6 million firearms are sold or transferred annually with no background checks. This loophole must be closed. In 2017, of the 25 million individuals who submitted to a background check to purchase or transfer possession of a firearm, 103 985 were prohibited purchasers and were blocked from making a purchase. While it is clear that background checks help to keep firearms out of the hands of individuals at risk of using them to harm themselves or others, the only way to ensure that all prohibited purchasers are prevented from legally acquiring firearms is to make background checks a universal requirement for all firearm purchases or transfers of ownership.

Need for Research on Firearm Injury and Death

Research to understand health-related conditions underpins the modern practice of medicine. In brief, medical research saves lives and improves health. Yet, despite bipartisan agreement that there are no prohibitions on the CDC’s ability to fund such research, research that would inform efforts to reduce firearm-related injury and death has atrophied over the last 2 decades. Consequently, we lack high-quality nationwide data on the incidence and severity of nonfatal firearm injuries. It is critical that the United States adequately fund research to help us understand the causes and effects of intentional and unintentional firearm-related injury and death in order to develop evidence-based interventions and make firearm ownership as safe as possible. Research should be nonpartisan and free of data restrictions to enable robust studies that identify robust solutions. Many of our organizations have affiliated with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), a nonprofit organization of health care professionals and researchers working to provide private funding for research related to firearm injury and its prevention. Both private and public funding are key to building a powerful evidence base on this important issue. Research for firearm injury and its prevention should be federally funded at a level commensurate with its health burden without restriction. To move from atrophy to strength requires not just allowing research, but also naming, appropriating, and directing funding for it and for the establishment of comprehensive data collection platforms to document the epidemiology of this growing public health crisis.

Intimate Partner Violence

Currently, federal laws prohibiting domestic abusers from accessing firearms do not apply to dating partners, even though almost half of intimate partner cases involved current dating partners. Federal law restricts firearm purchases by individuals who have been convicted of a domestic violence misdemeanor or have protective orders against them if they are a current or former spouse; a parent or guardian of the victim; a current or former cohabitant with the victim as a spouse, parent, or guardian; are similarly situated to a spouse, parent, or guardian of the victim; or have a child with the victim. It does not apply to dating partners, stalkers, or individuals who commit violence against another family member. This loophole in the background check system must be closed.

Safe Storage of Firearms

Keeping a firearm locked, keeping it unloaded, storing ammunition locked, and storing it in a separate location have all been associated with a protective effect. A 2018 study found that an estimated 4.6 million U.S. children are living in homes with at least 1 loaded and unlocked firearm. A large number of unintentional firearm fatalities occurred in states where firearm owners were more likely to store their firearms loaded, with the greatest risk in states where loaded firearms were more likely to be stored unlocked. Therefore, our organizations support child access prevention laws that hold accountable firearm owners who negligently store firearms under circumstances where minors could or do gain access to them. These laws are associated with a reduction of suicides and unintentional firearm injuries and fatalities among children.

Mental Health

The great majority of those with a mental illness or substance use disorder are not violent. However, screening, access, and treatment for mental health disorders play a critical role in reducing risk for self-harm and interpersonal violence. This is particularly of concern for adolescents, who are at high risk for suicide as a consequence of their often impulsive behavior. Access to mental health care is critical for all individuals who have a mental health or substance use disorder. This must include early identification, intervention, and treatment of mental health and substance use disorders, including appropriate follow-up. Those who receive adequate treatment from health professionals are less likely to commit acts of violence and individuals with mental illness are more likely to be victims rather than perpetrators of violence. Early identification, intervention, and access to treatment may reduce the risk for suicide and violence involving firearms for persons with tendencies toward those behaviors.

Extreme Risk Protection Orders

Several states have enacted ERPO or ERPO-style laws, and numerous other states are considering them. We support the enactment of these laws as they enable family members and law enforcement agencies to intervene when there are warning signs that an individual is experiencing a temporary crisis that poses an imminent risk to themselves or others while providing due process protections.

Physician Counseling of Patients and “Gag Laws”

Confidential conversations about firearm safety can occur during regular examinations when physicians have the opportunity to educate their patients and answer questions. Such conversations about mitigating health risks are a natural part of the patient–physician relationship. Because of this, our organizations oppose state and federal mandates that interfere with physicians’ right to free speech and the patient–physician relationship, including laws that forbid physicians from discussing a patient’s firearm ownership. Patient education using a public health approach will be required to lower the incidence of firearm injury in the United States. Our organizations are working on programs and strategies that engage firearm owners in devising scientifically sound and culturally competent patient counseling that clinicians can apply broadly.

In the privacy of an examination room, physicians can intervene with patients who are at risk of injuring themselves or others due to firearm access. They can also provide factual information about firearms relevant to their health and the health of their loved ones, answer questions, and advise them on the best course of action to promote health and safety. Providing anticipatory guidance on preventing injuries is something physicians do every day, and it is no different for firearms than for other injury prevention topics. To do so, physicians must be allowed to speak freely to their patients without fear of liability or penalty. They must also be able to document these conversations in the medical record just as they are able and often required to do with other discussions of behaviors that can affect health.

Firearms With Features Designed to Increase Their Rapid and Extended Killing Capacity

The need for reasonable laws and regulations compliant with the Second Amendment regarding high-capacity magazine–fed weapons that facilitate a rapid rate of fire is a point of active debate. Although handguns are the most common type of firearm implicated in firearm-related injury and death, the use of firearms with features designed to increase their rapid and extended killing capacity during mass violence is common. As such, these weapons systems should be the subject of special scrutiny and special regulation. There are various strategies to consider, and our organizations look forward to a greater engagement and partnership with responsible firearm owners to determine how best to achieve this goal.

Conclusion

Physicians are on the front lines of caring for patients affected by intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provide support for families affected by firearm-related injury and death. Physicians are the ones who inform families when their loved ones die as a result of firearm-related injury. Firearm violence directly impacts physicians, their colleagues, and their families. In a recent survey of trauma surgeons, one third of respondents had themselves been injured or had a family member or close friend(s) injured or killed by a firearm. As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society. Our organizations are committed to working with all stakeholders to identify reasonable, evidence-based solutions to stem firearm-related injury and death and will continue to speak out on the need to address the public health threat of firearms.

Understanding gun violence and mass shootings

Columbia University studies showed that public mass shootings, once a rare event, now occur with shocking frequency in the United States. According to the Washington Post, four or more people are killed in this horrific manner every 47 days. The most recent mass shootings, in Dayton, Ohio, and El Paso, Texas, occurred less than a day apart and resulted in the loss of 31 lives.

With each fresh assault, politicians and the public have become more firmly entrenched in their beliefs about the root causes of mass shootings and about possible solutions, from more restrictive gun control laws to better mental health care.

Researchers across Columbia University’s campuses have put these theories to the test in an effort to identify effective strategies for preventing mass shootings and other forms of gun violence.

Mental Illness

Mental illness has long been suspected as a primary cause of gun violence and mass shootings in particular. But only 3% to 5% of violent events are attributable to mental illness, writes Paul Appelbaum, MD, director of the Division of Law, Ethics, and Psychiatry at Columbia University Irving Medical Center, in an opinion article in JAMA Psychiatry. “Much of the increased risk [of violence] in people with mental disorders is attributable to other variables rather than to the disorders themselves. Substance abuse, for example, accounts for a large proportion of the incremental risk.”

Further, Appelbaum writes, “compilations of incidents of mass shootings suggest that people with severe mental disorders may be overrepresented among the perpetrators, but given the possibility of bias in the nonsystematic collection of such data, firm conclusions are impossible at this point.”

Video Games

With little funding to study gun violence, “we tend to fall back on conclusions unsupported by evidence,” says Sonali Rajan, EdD, assistant professor of health education at Columbia University Teachers College in an interview published on the school’s website.

In a study published in PLOS ONE, Rajan and colleagues from NYU Langone found no association between video games and other types of screen time and gun ownership among teens. The researchers analyzed data from the CDC’s Youth Risk Behavior Surveillance System—which surveyed tens of thousands of teens about 55 different behaviors over a period of 10 years—to identify factors associated with carrying a firearm. “Among the 5% to 10% of American teens who report regularly carrying a firearm, there is a much stronger association with substance use, engagement in physical fighting, and exposure to sexual violence than with any poor mental health indicator,” explains Rajan.

Gun Laws

States with more permissive gun laws and greater ownership of firearms had higher rates of mass shootings than states with more restrictions on gun ownership, according to a recent study by Columbia researchers in the British Medical Journal. “Our analyses reveal that U.S. gun laws have become more permissive in past decades, and the divide between permissive states and those with more stringent laws seems to be widening in concert with the growing tragedy of mass shootings in the U.S.,” says senior author Charles Branas, Ph.D., chair of epidemiology at Columbia University Mailman School of Public Health, in an article on the school’s website.

“What happened in Las Vegas saddens me deeply,” Branas says in a previous interview for the Mailman School website. “But this is only the tip of a much larger gun-violence iceberg in the U.S. On the same day, hundreds more people across the U.S. were shot, adding up to somewhere around 100,000 shootings a year.

“We need to think beyond simply guns and people, and start thinking about the environment that is promoting these shootings in the first place,” writes Branas, whose research also has focused on transforming abandoned housing and other signs of urban and rural blight to improve community health and safety.

In other countries, the implementation of laws restricting the purchase of and access to guns in other countries has also been associated with reductions in gun-related deaths, according to a study from researchers at Columbia University Mailman School of Public Health. “While the research did not conclusively prove that restrictions, or relaxation of laws, reduce gun deaths, the results indicate that gun violence tended to decline after countries passed new restrictions on gun purchasing and ownership,” says co-author Sandro Galea, Ph.D., in an interview for the school’s website.

Aftereffects

Recent suicides among survivors of the mass shootings at Sandy Hook Elementary School and Parkland High School show that the effects of such violent events are long-lasting and entrenched.

“The public may be affected [by mass shootings] even if they were not in immediate proximity, because the media reifies the effects of a mass violent incident,” says Jeffrey Lieberman, MD, chair of the Department of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons, in a recent video interview for Medscape.

For survivors of violent events, “reminders such as anniversaries can prolong complicated grief or even reactive grief and trauma,” writes Kathleen Pike, Ph.D., director of the Global Mental Health WHO Collaborating Centre at Columbia University, in an article published on the center’s website. “Community supports matter not only in the immediate aftermath of traumatic events but also for individuals who continue to suffer over time.”

GOP Waits to See if Trump Will Protect It From the NRA Before Moving on Gun Laws

Sam Brodey, Asawin Suebsaeng and Jackie Kucinich reported that just over a week since mass shootings in El Paso, Texas, and Dayton, Ohio, Senate Republicans are waiting to see if President Trump walks away from the issue again or forces their hand before trying to do anything about potentially expanding background checks for gun purchases.

He’s walked away before. Following the Parkland school massacre last year, the president promised that he was “going to be very strong on background checks,” only to retreat after holding private meetings with National Rifle Association officials at the White House. The NRA, a key ally of Trump’s, has spent big money lobbying against background-checks expansion legislation, and last week reminded him of its staunch opposition.

After the latest shootings, Trump told reporters that there is great “appetite” on the Hill to finally get something done on background checks but his GOP allies in the Senate are holding off, unwilling to burn political capital with the gun lobby and conservative-base voters on the issue if Trump isn’t going to burn some of his.

However, the president’s prior inaction, and the media coverage he incurred for it, may force him to make at least a slightly harder run at background checks this time around, even if only in his messaging and bluster. Two people who’ve spoken to the president in recent days say that he has referenced, during conversations about how he could possibly bend the NRA to his will in this case, his annoyance at media coverage of his post-Parkland about-face that suggested he was all talk and no action on the issue, and easily controlled by the NRA. One of the sources noted that Trump’s aversion to being seen as “controlled” by anyone or any organization makes it much more likely that the president will dwell on the issue for longer than he did last year.

Trump’s influence could well make or break legislation, since Republicans are unlikely to support anything without his blessing but will be just as hesitant to immediately reject a bill he puts his full support behind.

“Many Hill Republicans are waiting to see what Trump will get behind,” said a Senate GOP aide. “He gives them political cover. I don’t think you’re going to see any one bill or one proposal get any momentum until the President publicly endorses it.”

Senate Majority Leader Mitch McConnell (R-KY) said on Thursday that he and the president are actively discussing possible avenues for gun legislation. “He’s anxious to get an outcome and so am I,” said McConnell on a radio show in Kentucky.

The GOP leader stressed that the president was open to a discussion on gun legislation, from background checks to “red flag” bills: “Those are two items that for sure will be front and center as we see what we can come together on and pass.”

A spokesman for McConnell declined to elaborate on the Senate leader’s conversations with the president.

Democrats aren’t holding their breath, given that McConnell won’t call the Senate back from its recess for gun bills and that Trump has backtracked before on the issue after outcry from pro-gun factions of his base.

Democratic aides have been mindful of Sean Hannity’s reaction to the background checks push, since Trump’s position has been known to change based on the broadcasts or private counsel of Hannity and other top Fox personalities.

White House aides are similarly waiting on Trump, and talking up how he’s also been reaching out across the aisle to find a potential solution, even if nobody knows what that would look like yet. “The president has been actively talking to Republicans and Democrats on the matter of background checks, and just being able to have meaningful, measurable reforms that don’t confiscate law-abiding citizens’ firearms without due process, but at the same time keep those firearms out of people who have a propensity toward violence,” Kellyanne Conway, Trump’s White House counselor, said on this week’s Fox News Sunday.

One of those Democratic politicians, Sen. Joe Manchin (D-WV), said in a call with reporters on Wednesday he had spoken to the president twice since the shootings in Dayton and El Paso and that he was “committed to getting something done.”

While “everything is on the table,” Manchin said, Trump’s sign-off on any plan will be key to getting it through the Senate. The proposal introduced by Sen. Pat Toomey (R-PA) and Manchin in the months after the massacre at Sandy Hook elementary made modest adjustments to background check system by extending checks to gun shows and internet sales, but exempted gun transactions between friends and family members. It also provided additional funding to states to put critical information into the National Instant Criminal Background Check System in order to prevent people who should not have guns from obtaining them, and created a commission to study the causes of gun violence.

It’s a bill that’s failed twice, once in 2013 and again after the mass shooting in a San Bernardino office park in 2015. Both times it drew very limited support from Republican senators.

Asked what had changed since the last time the bill failed on the Senate floor, Manchin said, “The political will wasn’t there.”

Manchin said he was told by some colleagues who opposed the bill that they really didn’t object to the substance of the bill but they weren’t convinced the “Obama administration wouldn’t go further [and try] taking more of their guns away from them.”

Manchin said he tried to explain that would be unconstitutional, but to no avail.

Some Trump allies say that this president, given his record and rhetoric, might have just enough credibility among Second Amendment enthusiasts to drag them along, if he so chooses.

“If only Nixon could go to China, then maybe only Trump can address the chasm between gun owners and those who want gun control,” Michael Caputo, a former Trump campaign adviser, told The Daily Beast. “He’s so strong on the Second Amendment he can truly do something to make a change when it comes to these mass shootings.”

Caputo, who in 2013 and 2014 advised Trump on pro-gun voters and the NRA when the celebrity businessman was weighing a run for New York governor, said that even years ago, “We talked about mass shootings and what that means to the United States, and the importance [to voters] of the Second Amendment, and I know the president has been thinking about this issue for a long time: How you balance gun rights versus gun atrocities.”

Trump’s former adviser added, “If the president pursues broader background checks… perhaps it’s because he knows that is something only he can do. He may lose the support of some of the most pro-gun members of his base, but the vast majority of us understand there are some reasonable measures to be taken.”

I do have more data comparing the gun violence in the U.S.A. to other countries, which I will save until next week. But the most important point of this post is that those who can make the difference, i.e. the President and Congress have to ignore the NRA and do the right things. I have included a number of options and most important is that we all can not wait for another media circus as they cover the next mass shooting or jus any shooting, especially where the offending weapon is an assault weapon.

The Real Costs of the U.S. Health-Care Mess, South Africa’s cost of Health Care and Rural Health Care and Gun Violence

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How health insurance works now, and how the candidates want it to work in the future is confusing and yes, very costly.

Matt Bruenig reviewed that with more than 20 people vying for the Democratic presidential nomination, it can be difficult to get a handle on the policy terrain. This is especially true in health care, where at least eight different plans are floating around, including from candidates whom few support, such as Michael Bennet, who wants to offer a public health plan in the small individual-insurance market.

Among the candidates polling in the double digits, three have offered actual health-care proposals (as opposed to vague statements): Joe Biden, Kamala Harris, and Bernie Sanders, whose Medicare for All plan is also supported by Elizabeth Warren. These plans are similar in the most general sense, in that they expand coverage and affordability, but they are dramatically different in their particulars and in what they tell voters about the respective candidates. To understand any of that, however, you have to understand how insurance works right now.

Americans get insurance from four main sources.

The first source is Medicare, which covers nearly all elderly people and some disabled people. The “core” program consists of Medicare Part A, which pays for hospital treatment, and Medicare Part B, which pays for doctor visits. Medicare Part D covers prescription drugs but is administered only by private insurance providers. Private Medigap plans provide supplemental insurance for some of the cost-sharing required by Parts A and B, while private Medicare Advantage plans essentially bundle all of the above into a single offering.

The second source is Medicaid, which covers low-income people and provides long-term care for disabled people. Medicaid is administered by states and jointly funded by state and federal governments. The Affordable Care Act expanded Medicaid eligibility up to the income ladder a bit, but some states did not go along with the expansion.

The third source is employer-sponsored insurance, which covers about 159 million workers, spouses, and children. Employer insurance is very costly, with the average family premium running just under $19,000 a year. For average wage workers living in a family of four, this premium is equal to 26.4 percent of their total labor compensation. If you count this premium as taxes for international comparison purposes, the average wage worker in the United States has the second-highest tax rate in the developed world, behind the Netherlands. As with Medicaid, employer insurance is very unstable, with people losing their insurance plan every time they separate from their job (66 million workers every year) or when their employer decides to change insurance carriers (15 percent of employers every year).

The final source is individual insurance purchased directly from a private insurer. Most of the people who buy this kind of insurance do so through the exchanges established by the Affordable Care Act. The exchanges provide income-based subsidies to individuals with incomes from 100 percent to 400 percent of the poverty line, but have mostly been a policy train wreck: Enrollments were 50 percent lower than predicted, insurers have quit the exchanges in droves, and the income cutoffs have caused disgruntlement among low-income participants who would rather have Medicaid and high-income participants who get no subsidy at all.

Despite all of this, or perhaps because of it, America still has about 30 million uninsured people, a number that is predicted to increase to 35 million by 2029. Conservative estimates suggest that there is one unnecessary death annually for every 830 uninsured people, meaning that America’s level of uninsurance leads to more than 35,000 unnecessary deaths every year.

Biden has centered his candidacy on his association with Barack Obama. Given this strategy, it’s no surprise that he has put out a health plan that is meant to be as similar to Obamacare as possible.

The plan keeps the current insurance regime intact while tweaking some of the rules to fix a few of the pain points identified above. He closes the hole created by some states not expanding Medicaid by enrolling everyone stuck in that hole into a new public health plan for free. He soothes the disgruntlement of high-income people who buy unsubsidized individual insurance by extending subsidies beyond 400 percent of the poverty line. And he slightly increases the subsidy amount for those buying subsidized individual insurance on the exchanges.

In addition to these rule tweaks, Biden also says that the new public option for everyone in the Medicaid hole will also be available in the individual and employer insurance markets, meaning that people in those markets can buy into that public option rather than rely on private insurance.

Biden is probably correct to say that his plan is the most similar to Obamacare. And just like Obamacare, Biden’s plan will leave a lot of Americans uninsured. Specifically, his own materials say that 3 percent of Americans will still be uninsured after his reforms, which means that about 10 million Americans will continue to lack insurance and about 12,000 will die each year due to uninsurance.

Sanders is running as a progressive democratic socialist who wants America to offer the kinds of benefits available in countries such as Denmark, Finland, Sweden, and Norway, or in even less left-wing countries such as Canada. Unlike Biden, he has no need or desire to wrap himself in the policies of the Obama era and has instead come out in favor of a single-payer Medicare for All system.

Under the Sanders plan, the federal government will provide comprehensive health insurance that covers nearly everything people associate with medical care, including prescription drugs, hearing, dental, and vision. Over the course of four years, every American will be transitioned to the new public health plan. Going forward, rather than getting money to providers through a mess of leaky insurance channels, all money will flow through the single Medicare channel, which will cover everyone.

So far, Sanders has not adopted a specific set of “pay-fors” for his Medicare for All program but has instead offered up lists of funding options. Although he has remained open on the specifics of funding Medicare for All, the overall Sanders vision is pretty clear: cut overall health spending while also redistributing health spending up the ladder so that the majority of families pay less for health care than they do now.

And this plan is plausible: The right-wing Mercatus Center found in 2018 that the Sanders plan reduces overall health spending by $2 trillion in the first 10 years. The nonpartisan Rand Corporation has constructed a similar single-payer plan, with pay-fors, for New York State that would result in health-care savings for all family income-groups below 1,000 percent of the poverty line ($276,100 for a family of four).

While Sanders’s support for Medicare for All helps promote his image as a supporter of universal social programs, Warren’s support for it helps boost her brand as a smart technocrat who understands good policy design. As Paul Krugman noted in 2007, a single-payer Medicare for All system is “simpler, easier to administer, and more efficient” than the “complicated, indirect” health-care system we have now. In general, single-payer systems are beloved by the wonk set because they are the most direct and cost-effective way to provide universal health insurance to a population.

If Biden’s plan is Obamacare 2.0 and the Sanders/Warren plan is wonky universalism, then Harris’s plan is a bizarre and confusing muddle that also has come to typify her campaign. Harris is the candidate who went hard after Biden for his views on busing many decades ago and then clarified the next day that her views are the same as Biden’s. She’s the candidate who said she wanted to get rid of private insurers and raised her hand when asked if she would be willing to swap out private insurance for Medicare for All, only to walk back both statements the very next day.

Harris’s health-care proposal, which is basically Medicare Advantage for All, is similar to the Sanders plan, except it takes 10 years to phase in instead of four and allows people to opt out of the public plan in favor of a private plan with identical coverage (similar to how Medicare Advantage works today). This weird hybrid allows Harris to insist that she is for Medicare for All while also saying that she is not getting rid of private insurance.

As readers can probably guess, I favor the Sanders plan on the merits. But what matters for voters may not be the particulars, which most voters will probably never be aware of, but rather what the plans say about the candidates. Voters who want Obama 2.0 will see in Biden’s health-care plan a reassuring fidelity to his predecessor. Voters interested in universal social programs or technocratic wonkiness will have another reason to like Sanders or Warren based on their Medicare for All plan. And voters who like Harris’s style and do not care about consistency can use Harris’s triangulated health-care policy to see what they want in her.

South Africa puts initial universal healthcare cost at $17 billion

I thought that it would be a great idea to see how much other countries are paying for their health care plans. Onke Ngcuka noted that South Africa published its draft National Health Insurance (NHI) bill on Thursday, with one senior official estimating universal healthcare for millions of poorer citizens would cost about 256 billion rands ($16.89 billion) to implement by 2022.

The bill creating an NHI Fund paves the way for a comprehensive overhaul of South Africa’s health system that would be one of the biggest policy changes since the ruling African National Congress ended white minority rule in 1994.

The existing health system in Africa’s most industrialized economy reflects broader racial and social inequalities that persist more than two decades after apartheid ended.

Less than 20 percent of South Africa’s population of 58 million can afford private healthcare, while a majority of poor blacks queue at understaffed state hospitals short of equipment.

Anban Pillay, deputy director-general at the health department, told reporters an initial Treasury estimate of 206 billion rand costs by 2022 was more likely to be 256 billion rands by the time final numbers had been reviewed.

The bill proposes that the NHI Fund, with a board and chief executive officer, also be funded from additional taxes.

“The day we have all been waiting for has arrived: today the National Health Insurance Bill is being introduced in parliament,” said Health Minister Zweli Mkhize at the briefing, adding that the pooling of existing public funds should help reduce costs.

The Hospital Association of South Africa (HASA), an industry body which represents private hospital groups including Netcare, Mediclinic and Life Healthcare, welcomed the release of the bill.

“We are committed to, and supportive of, the core purpose of the legislation, which is to ensure access to quality healthcare for all South Africans,” said HASA chairman Biren Valodia in a statement.

“TAX BURDEN”

The new bill is still to be debated in parliament with public input. It is unclear how long the legislative process will take, with the main opposition party Democratic Alliance suggesting the NHI, which has been in the works for around a decade, would strain the nation’s coffers.

“The DA is convinced that instead of being a vehicle to provide quality healthcare for all, this Bill will nationalize healthcare … and be an additional tax burden to already financially-stretched South Africans,” said Siviwe Gwarube, the DA’s shadow health minister, in a statement.

Successful implementation of NHI would be a boon for President Cyril Ramaphosa following May’s election the ANC won, but its cost comes at a tricky time in a struggling economy.

South Africa’s rand fell to touch an 11-month low on Wednesday, rocked by deepening concerns about the outlook for domestic growth with unemployment at its highest in over a decade and the economy skirting recession.

New taxation options for the Fund include evaluating a surcharge on income tax and small payroll-based taxes.

“There is no doubt that taxpayers will find the additional tax burden a bitter pill to swallow,” said Aneria Bouwer, a partner and tax specialist at Bowmans law firm.

The NHI is due to be implemented in phases before full operation by 2026. The government is looking to eventually shift into the new Fund approximately 150 billion rands a year from money earmarked for the provincial government sphere.

Rural hospitals take the spotlight in the coverage expansion debate

Susannah Luthi points out a fact of these health care plans which everyone refuses to believe. Opponents of the public option have funded an analysis that warns more rural hospitals may close if Americans leave commercial plans for Medicare.

With the focus on rural hospitals, the Partnership for America’s Health Care Future brings a sensitive issue for politicians into its fight against a Medicare buy-in. The policy has gone mainstream among Democratic presidential candidates and many Democratic lawmakers.

Rural hospitals could lose between 2.3% and 14% of their revenue if the U.S. opens up Medicare to people under 65, the consulting firm Navigant projected in its estimate. The analysis assumed just 22% of the remaining 30 million uninsured Americans would choose a Medicare plan. The study based its projections of financial losses primarily on people leaving the commercial market where payment rates are significantly higher than Medicare.

The estimate assumed Medicaid wouldn’t lose anyone to Medicare and plotted out various scenarios where up to half of the commercial market would shift to Medicare.

The analysis was commissioned by the Partnership for America’s Health Care Future, a coalition of hospitals, insurers and pharmaceutical companies fighting public option and single-payer proposals.

In their most drastic scenario of commercial insurance losses, co-authors Jeff Goldsmith and Jeff Leibach predict more than 55% of rural hospitals could risk closure, up from 21% who risk closure today according to their previous studies.

Leibach said the analysis was tailored to individual hospitals, accounting for hospitals that wouldn’t see cuts since they don’t have many commercially insured patients.

The spotlight on rural hospitals in the debate on who should pay for healthcare is common these days, particularly as politicians or the executive branch eye policies that could cut hospital or physician pay.

On Wednesday, Sen. Elizabeth Warren (D-Mass.) seemingly acknowledged this when she published her own proposal to raise Medicare rates for rural hospitals as part of her goal to implement single-payer or Medicare for All. She is running for the Democratic nomination for president for the 2020 election.

“Medicare already has special designations available to rural hospitals, but they must be updated to match the reality of rural areas,” Warren said in a post announcing a rural strategy as part of her campaign platform. “I will create a new designation that reimburses rural hospitals at a higher rate, relieves distance requirements and offers the flexibility of services by assessing the needs of their communities.”

Warren is a co-sponsor of the Medicare for All legislation by Sen. Bernie Sanders (I-Vt.), who is credited with the party’s leftward shift on the healthcare coverage question. But she is trying to differentiate herself from Sanders, and the criticisms about the potentially drastic pay cuts to hospitals have dogged single-payer debates.

Most experts acknowledge the need for a significant policy overhaul that lets rural hospitals adjust their business models. Those providers tend to have aging and sick patients; high rates of uninsured and public pay patients over those covered by commercial insurance; and fewer patients overall than their urban counterparts.

But lawmakers in Washington aren’t likely to act during this Congress. The major recent changes have mostly been driven by the Trump administration, where officials just last week finalized an overhaul of the Medicare wage index to help rural hospitals.

As political rhetoric around the public option or single-payer has gone mainstream this presidential primary season, rural hospitals will likely remain a talking point in the ideas to overhaul or reorganize the U.S.’s $3.3 trillion healthcare industry.

This was in evidence in May, when the House Budget Committee convened a hearing on Medicare for All to investigate some of the fiscal impacts. One Congressional Budget Office official said rural hospitals with mostly Medicaid, Medicare, and uninsured patients could actually see a boost in a redistribution of doctor and hospital pay.

But the CBO didn’t analyze specific legislation and offered a vague overview of how a single-payer system might look, rather than giving exact numbers.

The plight of rural hospitals has been used in lobbying tactics throughout this year — in Congress’ fight over how to end surprise medical bills as well as opposition to hospital contracting reforms proposed in the Senate.

And it has worked to some extent. Both House and Senate committees have made concessions to their surprise billing proposals to mollify some lawmakers’ worries.

New research finds restructuring Medicare Shared Savings Program can yield 40% savings in healthcare costs, bolstering payments to providers

As I reviewed in the last few posts, the evaluation of Medicare was underestimated regarding the cost of the program many times.  Ashley Smith reported that more than a trillion dollars were spent on healthcare in the United States in 2018, with Medicare and Medicaid accounting for some 37% of those expenditures. With healthcare costs expected to continue to rise by roughly 5% per year, a continued debate in healthcare policy is how to reduce costs without compromising quality.

As part of this effort, the Medicare Shared Savings Program was created to control escalating Medicare spending by giving healthcare providers incentives to deliver more efficient healthcare.

New research published in the INFORMS journal Operations Research offers a new approach that could substantially change the healthcare spending paradigm by utilizing performance-based incentives to drive down spending.

The researchers Anil Aswani and Zuo-Jun (Max) Shen of the University of California, Berkeley, and Auyon Siddiq of the University of California, Los Angeles found that redesigning the contract for the shared savings program to better align provider incentives with performance-based subsidies can both increase Medicare savings and increase providers’ reimbursement payments.

“Introducing performance-based subsidies can boost Medicare savings by up to 40% without compromising provider participation in the shared savings program,” said Aswani, a professor in the Industrial Engineering and Operations Research Department at UC Berkeley. “This contract can lead to improved outcomes for both Medicare and participating providers,” he continued.

So, again Medicare will be tweaked and reworked for the present aging population.

What will happen with the Medicare program if it applies to all and at what cost?

And finally, we physicians are on the front lines of caring for patients affected by the intentional or unintentional firearm-related injury. We care for those who experience a lifetime of physical and mental disability related to firearm injury and provides support for families affected by firearm-related injury and death. Physicians are the ones who inform families when their loved ones die as a result of the firearm-related injury. Firearm violence directly impacts physicians, their colleagues, and their families. In a recent survey of trauma surgeons, one-third of respondents had themselves been injured or had a family member or close friend(s) injured or killed by a firearm (38). As with other public health crises, firearm-related injury and death are preventable. The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues, and our society. Our organizations are committed to working with all stakeholders to identify reasonable, evidence-based solutions to stem firearm-related injury and death and will continue to speak out on the need to address the public health threat of firearms and I will discuss this in more detail in the following weeks.

First, we have to ignore the NRA and make a difference in order to decrease the increasing gun violence!!!!! I predict that if the President and the Republican Senate doesn’t make inroads they are doomed to fail in the 2020 election.

 

 

Medicare for All, funding and ‘impossible promises’ deeply divide Democrats during 2020 debate; and How Many More Shootings of Innocent people Can Our Society Tolerate?

 

promise312What a horrible week it has been! The debates were an embarrassment for all, both Democrats as well as everyone else. Who among those twenty who were on stage, spouting impossible strategies, attacking each other and in general making fools of themselves.

But the worst was the mass shootings this past weekend. Why should anybody be allowed to own assault weapons? We all need to finally do something about this epidemic of mass shootings. How many more innocent people do we have to lose before the Republicans, as well as the Democrats and our President, work together to solve this problem.

As the President of the American Medical Association stated:

“The devastating gun violence tragedies in our nation this weekend are heartbreaking to physicians across America. We see the victims in our emergency departments and deliver trauma care to the injured, provide psychiatric care to the survivors, and console the families of the deceased. The frequency and scale of these mass shootings demand action.

“Everyone in America, including immigrants, aspires to the ideals of life, liberty, and pursuit of happiness. Those shared values – not hatred or division – are the guiding light for efforts to achieve a more perfect union.

“Common-sense steps, broadly supported by the American public, must be advanced by policymakers to prevent avoidable deaths and injuries caused by gun violence. We must also address the pathology of hatred that has too often fueled these mass murders and casualties.”

Brittany De Lea when reviewing the Democrat presidential hopefuls noted that Democratic contenders for the 2020 presidential election spent a sizable amount of time during the second round of debates detailing the divide over how the party plans to reform the U.S. health care system – while largely avoiding to address how they would pay for their individual proposals.

Massachusetts Sen. Elizabeth Warren dodged a point-blank question from moderators as to whether middle-class families would pay more in taxes in order to fund a transition to a Medicare for All system.

Instead, she said several times that “giant corporations” and “billionaires” would pay more. She noted that “total costs” for middle-class households would go down.

Independent Vermont Sen. Bernie Sanders said during the first round of Democratic debates in Miami that taxes on middle-class families would rise but added that those costs would be offset by lower overall health care costs. Warren seemed to refer to this plan of action also.

Sanders and Warren quickly became targets on the debate stage for his proposed plan, which she supports, to transition to a Medicare for All system where there is no role for private insurers.

Former Maryland Congressman John Delaney (and even though I am not a big fan of Mr. Delaney, he is the only one that makes any sense with regard to health care) said Sanders’ plan would lead to an “underfunded system,” where wealthy people would be able to access care at the expense of everyone else. He also said hospitals would be forced to close.

Delaney asked why the party had to be “so extreme,” adding that the Democrats’ health care debate may not be so much about health care as it was an “anti-private sector strategy.” In his opening statement, he appeared to throw jabs at Sanders and Warren for “impossible promises” that would get Trump reelected.

Former Texas lawmaker Beto O’Rourke said taxes would not rise on middle-class taxpayers, but he also does not believe in taking away people’s choice for the private insurance they have.

Minnesota Sen. Amy Klobuchar said there needed to be a public option, as did former Colorado Gov. John Hickenlooper.

South Bend, Indiana, Mayor Pete Buttigieg thought the availability of a public alternative would incentivize people to walk away from their workplace plans.

Earlier this week, California Sen. Kamala Harris unveiled her vision for a transition to a Medicare for All system over a 10-year phase-in period, which called for no tax increase on families earning less than $100,000. She instead said a Wall Street financial transaction tax would help fund the proposal.

Harris is scheduled to appear during Wednesday’s night debate in Detroit, alongside former Vice President Joe Biden whose campaign has already criticized her health care plan.

Health care comes in focus, this time as a risk for Democrats

Ricardo Alonso-Zaldivar reported that the Democratic presidential candidates are split over eliminating employer-provided health insurance under “Medicare for All.”

The risk is that history has shown voters are wary of disruptions to job-based insurance, the mainstay of coverage for Americans over three generations.

Those divisions were on display in the two Democratic debates this week, with Sens. Bernie Sanders and Elizabeth Warren calling for a complete switch to government-run health insurance for all. In rebuttal, former Vice President Joe Biden asserted, “Obamacare is working” and promised to add a public option. Sen. Kamala Harris was in the middle with a new Medicare for All concept that preserves private insurance plans employers could sponsor and phases in more gradually. Other candidates fall along that spectrum.

The debates had the feel of an old video clip for Jim McDermott, a former Democratic congressman from Washington state who spent most of his career trying to move a Sanders-style “single-payer” plan and now thinks Biden is onto something.

“There is a principle in society and in human beings that says the devil you know is better than the devil you don’t know,” said McDermott, a psychiatrist before becoming a politician. “I was a single-payer advocate since medical school. But I hit every rock in the road trying to get it done. This idea that you are going to take out what is known and replace it with a new government program — that’s dead on arrival.”

Warren, D-Mass., was having none of that talk Monday night on the debate stage. “Democrats win when we figure out what is right, and we get out there and fight for it,” she asserted.

Confronting former Rep. John Delaney, D-Md., a moderate, Warren said, “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for. … I don’t get it.”

Here’s a look at options put forward by Democrats and the employer-based system that progressives would replace:

MEDICARE FOR ALL

The Medicare for All plan advocated by Sanders and Warren would replace America’s hybrid system of employer, government and individual coverage with a single government plan paid for by taxes. Benefits would be comprehensive, and everybody would be covered, but the potential cost could range from $30 trillion to $40 trillion over 10 years. It would be unlawful for private insurers or employers to offer coverage for benefits provided under the government plan.

“If you want stability in the health care system, if you want a system which gives you freedom of choice with regard to doctor or hospital, which is a system which will not bankrupt you, the answer is to get rid of the profiteering of the drug companies and the insurance companies,” said Sanders, a Vermont senator.

BUILDING ON OBAMACARE

On the other end is the Biden plan, which would boost the Affordable Care Act and create a new public option enabling people to buy subsidized government coverage.

“The way to build this and get to it immediately is to build on Obamacare,” he said.

The plan wouldn’t cover everyone, but the Biden campaign says it would reach 97% of the population, up from about 90% currently. The campaign says it would cost $750 billion over 10 years. Biden would leave employer insurance largely untouched.

Other moderate candidates take similar approaches. For example, Colorado Sen. Michael Bennet’s plan is built on a Medicare buy-in initially available in areas that have a shortage of insurers or high costs.

THE NEW ENTRANT

The Harris plan is the new entrant, a version of Medicare for All that preserves a role for private plans closely regulated by the government and allows employers to sponsor such plans. The campaign says it would cover everybody. The total cost is uncertain, but Harris says she would not raise taxes on households making less than $100,000.

“It’s time that we separate employers from the kind of health care people get. And under my plan, we do that,” Harris said.

Harris’ plan might well reduce employer coverage, while Sanders’ plan would replace it. Either would be a momentous change.

Job-based coverage took hold during the World War II years, when the government encouraged employers and unions to settle on health care benefits instead of wage increases that could feed inflation. According to the Congressional Budget Office, employers currently cover about 160 million people under age 65 — or about half the population.

A poll this week from the nonpartisan Kaiser Family Foundation underscored the popularity of employer coverage. Among people 18-64 with workplace plans, 86% rated their coverage as good or excellent.

Republicans already have felt the backlash from trying to tamper with employer coverage.

As the GOP presidential nominee in 2008, the Arizona Sen. John McCain proposed replacing the long-standing tax-free status of employer health care with a tax credit that came with some limits. McCain’s goal was to cut spending and expand access. But Democrats slammed it as a tax on health insurance, and it contributed to McCain’s defeat by Barack Obama.

“The potential to change employer-sponsored insurance in any way was viewed extremely negatively by the public,” said economist Douglas Holtz-Eakin, who served as McCain’s policy director. “That is the Achilles’ heel of Medicare for All — no question about it.”

These Are the Health-Care Questions That Matter Most

Max Nisen then noted that Health care got headline billing at both of this week’s second round of Democratic presidential debates. Unfortunately for voters, neither was very illuminating.

The biggest culprit was the format. Jumping between 10 candidates every 30 seconds made any substantive debate and discussion impossible. The moderators also deserve blame; they asked myopic questions intended to provoke conflict instead of getting any new information. And the candidates didn’t exactly help; there was a lot of sniping and not a lot of clear explanation of what they wanted to do.

The next debates may well be an improvement, as a more stringent cutoff should help to narrow the field and give candidates added time to engage in thoughtful discourse. Regardless, here are the issues that matter, and should be at the heart of any discussion:

The issue of how candidates would propose paying for their various health-care plans has been framed in the debates by the question, “Will you raise middle-class taxes?” That’s a limited and unhelpful approach. Raising taxes shouldn’t be a yes or no question; it’s a trade-off. Americans already pay a lot for health care in the form of premiums, deductibles, co-payments, and doctor’s bills. Why is that regressive system, which rations care by income, different or better than a more progressive tax?  Insurer and drug maker profits, both of which got airtime at the debates, are only a part of the problem when it comes to America’s high health costs.  The disproportionately high prices Americans pay for care are a bigger issue. What we pay hospitals and doctors, and how we can bring those costs down, are crucial issues that the candidates have barely discussed. What’s their plan there? The first round of debates saw the moderators ask candidates to raise their hands if they would eliminate private health coverage. Round two did essentially the same thing without the roll call. The idea of wiping out private insurance seems to be a flashpoint, but there doesn’t seem to be as much interest in questioning the merits of the current, mostly employer-based system. It’s no utopia. Americans unwillingly lose or change employer coverage all the time, and our fragmented system does an awful job of keeping costs down. People who support eliminating or substantially reducing the role of private coverage deserve scrutiny, but so do those who want to retain it. What’s so great about the status quo?

Screen Shot 2019-08-05 at 12.14.52 AM

As the field narrows, voters need specifics. A chunk of the field has been remarkably vague. Answers to these questions could offer some clarity:

For Senator Elizabeth Warren: Are there any differences between your vision of “Medicare for All” and Senator Bernie Sanders’s? There’s wiggle room here; his plan is more expansive (and expensive) than single-payer systems in countries like Canada.  For Senator Kamala Harris: What will your plan cover and how much will it cost? The skeletal outline of Harris’s plan lacks details on premiums and what patients would have to pay for out of pocket. She didn’t clarify matters at the debate.  For former Vice President Joe Biden: Will people with access to employer insurance be eligible for subsidies in your public option plan? If the answer is no or restrictive, his public option could have a relatively limited impact. It the answer is yes, his $750 billion cost estimate should head to the dustbin.  For the morass of candidates who pay lip service to Medicare for All but want to keep private insurance but don’t have a specific plan: What exactly do you want?

Health care is the most important issue for Democrats, according to polling. We need to find a way to have a discussion that does it justice.

Democrats’ Health-Care Feud Eclipses Message That Won in 2018

So, what have we learned from these debates? John Tozl realizes that in the four evenings of Democratic presidential debates since June, one phrase appeared for the first time on Wednesday: “pre-existing conditions.”

New Jersey Senator Cory Booker uttered it in his remarks on health care, chiding fellow Democrats for their infighting as Republicans wage a legal battle to undo the Affordable Care Act, which prohibits insurers from charging people more for being sick.

“The person who is enjoying this debate the most tonight is Donald Trump,” he said. “There is a court case working through the system that’s going to gut the Affordable Care Act and actually gut protections on pre-existing conditions,” Booker said, citing litigation in which the Trump administration and Republican-controlled states seeking to strike down Obamacare.

Over two nights this week, the 20 candidates spent at least an hour fiercely arguing over health-care plans, most of which are significantly more expansive than what the party enacted a decade ago in the Affordable Care Act. It’s a sign of how important the issue will be in the bid to unseat Trump, and how the party’s position has shifted leftward.

In November, Democrats won control of the House on the strength of their message to protect people with pre-existing conditions. That provision, a fundamental change to America’s private insurance market, is central to the ACA, the party’s most significant domestic policy achievement in a generation.

Booker’s attempt to unify his fractious colleagues against their common opponent stood out, because most of the discussion of health care, which kicked off the debate as it did on Tuesday, but the party’s divisions into sharp focus.

Biden v. Harris

Senator Kamala Harris of California and former Vice President Joe Biden tried to discredit each other’s proposals. Biden says he wants to build on the Affordable Care Act while expanding access to health insurance through a public insurance option.

Harris, in a plan, unveiled this week, likewise favors a public option but wants to sever the link between employment and health insurance, allowing people instead to buy into public or private versions of Medicare, the federal health-care program for seniors.

Harris took Biden to task over a plan that fails to insure everyone, saying his plan would leave 10 million people without insurance.

“For a Democrat to be running for president in America with a plan that does not cover everyone, I think is without excuse,” she said.

Biden accused Harris of having had “several plans so far” and called her proposal a budget-buster that would kick people off health plans they like.

“You can’t beat President Trump with double-talk on this plan,” he said.

Other candidates split along similar lines, with Colorado Senator Michael Bennet saying Harris’s proposal “bans employer-based insurance and taxes the middle class to the tune of $30 trillion.”

New York Mayor Bill de Blasio argued for a more sweeping approach, like the Medicare for All policies embraced by Senators Bernie Sanders and Elizabeth Warren.

“I don’t understand why Democrats on this stage are fear-mongering about universal health care,” he said. “Why are we not going to be the party that does something bold, that says we don’t need to depend on private insurance?”

How Bold?

The question any candidate will eventually have to answer is how bold a plan they believe voters in a general election want.

In 2018, Democrats running for Congress attacked Republicans for trying to repeal the ACA and then, when that failed, asking courts to find it unconstitutional. Scrapping the law would mean about 20 million people lose health insurance.

About two-thirds of the public, including half of Republicans, say preserving protections for people with pre-existing conditions is important, according to polls by the Kaiser Family Foundation, a nonprofit health research group.

More than a quarter of adults under 65 have pre-existing conditions, Kaiser estimates.

But that message has been mostly absent from the primary debates, where health-care talk highlights the divisions between the party’s progressive left-wing and its more moderate center.

Warren and Sanders weren’t on stage Wednesday, but their presence was looming. They’re both leading candidates and have deeply embraced Medicare for All plans that replace private insurance with a government plan. Bernie is an idiot, especially in his come back that he knows about Medicare for All since he wrote the bill. He has no idea of the far-reaching effect of Medicare for all. Our practice just reviewed our payments from Medicare over the last few years as well as the continued discounts that are applied to our services and noted that if we had to count on Medicare as our only health care payer that we as well as many rural hospitals would go out of business.

I refer you all back to John Delaney’s responses to the Medicare for All discussion. In the middle of a vigorous argument over Medicare for All during the Democratic debate tonight, former Representative John Delaney pointed out the reason he doesn’t support moving all Americans onto Medicare: It generally pays doctors and hospitals less than private-insurance companies do.

Because of that, some have predicted that if private insurance ends, and Medicare for All becomes the law of the land, many hospitals will close, because they simply won’t be able to afford to stay open at Medicare’s rates. Fact-checkers have pointed out that while some hospitals would do worse under Medicare for All, some would do better. But Delaney insisted tonight that all the hospital administrators he’s spoken with have said they would close if they were paid at the Medicare rate for every bill.

Whichever candidate emerges from the primary will have to take their health plans not just to fervent Democrats, but to a general electorate as well.

More on Medicare

If you remember from last week I reviewed the inability of our federal designers to accurately estimate the cost of the Medicare program and the redesign expanding the Medicaid programs mandating the states expand their Medicaid programs to provide comprehensive coverage for all the medically needy by 1977.

The additional provision of the 1972 legislation was the establishment of the Professional Standards Review Organizations (PSROs), whose function it was to assume responsibility for monitoring the costs, degree of utilization, and quality of care of medical services offered under Medicare and Medicaid. It was hoped that these PSROs would compel hospitals to act more efficiently. In keeping with this set of goals, in 1974 a reimbursement cap was instituted that limited hospitals from charging more than 120 percent of the mean of routine costs in effect in similar facilities, a limit eventually reduced to 112 percent named as Section 223 limits. But despite these attempts at holding down costs, they continued to escalate inasmuch as hospitals were still reimbursed on the basis of their expenses and the caps that were instituted applied only to room and board and not to ancillary services, which remained unregulated.

Now think about the same happening on a bigger scale with the proposed Medicare for All. Those that are proposing this “Grand Plan” need to understand the complexities issues, which need to be considered before touting the superiority of such a plan. Otherwise, the plan will fail!! Stop your sputtering arrogance Bernie, Kamala, and Elizabeth, etc. Get real and do you research, your homework before you yell and scream!!!!!!

More to Come!