What the New Democratic House majority might actually pass on health care; and It Looks Like VA Healthcare Maybe Improving!

 

 

18670832_1206383419491315_6469395384583311089_nI had prepared two posts for tonight and wanted to hold off on the recent shootings until next week as we digest what the effect really is in our country and the future strategies. Now let’s discuss the effect of the election and in looking at the House Democrats, who have a lot to figure out on their signature issue.

Healthcare carried House Democrats to victory on Election Day. But what now?

Remember my past post reminding the Republicans the importance of healthcare in the midterm elections? We, it looks like it was an important factor in the outcomes of the “wave”. Dylan Scott spent some time looking at his prediction of what the new majority will bring to our health care system. In interviews this fall with half a dozen senior House Democratic aides, health care lobbyists, and progressive wonks, it became clear the party is only in the nascent stages of figuring out its next steps on health care.

The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare.

But Democrats are less certain about an affirmative health care agenda. Most Democrats campaigned on protecting preexisting conditions, but the ACA has already done that. Medicare-for-all is energizing the party’s left wing, but nobody expects a single-payer bill to start moving through the House. Drug prices offer the rare opportunity for bipartisan work with Senate Republicans and the Trump White House, but it is also a difficult problem with few easy policy solutions — certainly not any silver bullet that Democrats could pull out of the box and pass on day one, or even month one, of the next Congress.

Winning a House majority to ensure Obamacare’s safety is an important turning point after so many years in which health care hurt Democrats much more than it helped.

But the path forward for the party on their signature issue is surprisingly undefined.

The likely first item on the Democratic agenda: Obamacare stabilization

Democrats do have some ideas, of course. Democratic aides emphasized the various investigations they could launch into Trump’s health department, not only looking into any efforts by the White House to sabotage Obamacare but also focusing on more obscure issues like Medicare payment rates.

But wonky oversight inquiries probably aren’t the big-ticket item that new Democratic members and their voters are looking for, especially heading into the 2020 presidential election.

After campaigning in defense of Obamacare, warning about Republicans rolling back preexisting conditions protections and the Trump administration’s sabotage of the health care law, a bill to stabilize the Obamacare insurance markets would be the obvious first item for the new Democratic majority’s agenda.

Several sources pointed to a bill by Democratic Reps. Richard Neal (MA), Frank Pallone (NJ), and Bobby Scott (VA) — who have been serving as the top Democrats on leading health care-related committees — as the likely starting point. The plan is designed to build off Obamacare’s infrastructure to expand federal assistance while reversing the recent Republican efforts to undermine the law.

That bill would expand Obamacare’s premium subsidies, both by extending federal assistance to more people in lifting the current eligibility cutoff and by increasing the size of the tax credits people receive. It would also bolster the cost-sharing reduction subsidies that people with lower incomes receive to reduce their out-of-pocket costs while extending eligibility for those subsidies to people with higher incomes.

The Pallone-Neal-Scott bill would reverse the Trump administration’s recent regulations intended to funnel more people to insurance plans that are not required to meet all of Obamacare’s rules for preexisting conditions. It would also pump more money back into enrollment outreach, cut by the Trump administration, and establish a new program to compensate insurers for high-cost patients, with the hope of keeping premiums down.

Two things stick out about this bill: It would be the most robust expansion of Obamacare since the law first passed, and it is just narrow enough that, with a few sweeteners for Senate Republicans, it could conceivably have a chance to pass. Democrats are waiting to see how the GOP majority in the upper chamber reacts to losing the House.

“Undoing sabotage and bringing stabilization to the ACA markets, that’s something we should really be thinking about,” one House Democratic aide told me. “It depends on what kind of mood the Republicans are in. Maybe they’ll say that actually now that the tables are turned, we should probably sit down.”

Senate Republicans and Democrats did come very close to a narrow, bipartisan deal — it wasn’t even as robust as the Pallone-Neal-Scott bill — to stabilize Obamacare in 2017. It fell apart, ostensibly after a tiff over abortion-related provisions, but that near miss would be the reason for any optimism about a bipartisan deal on the divisive health care law.

Then again Senate Republicans might have no interest in an Obamacare compromise after gaining some seats. Democrats would still likely work on stabilization to send a message to voters on health care ahead of the 2020 campaign.

Shoring up Obamacare is a good start, but what next?

In the case, the Pallone-Neal-Scott bill might be a nice starting point — no Democrat really disagrees about whether they should help the law work better in the short term — but it still lacks any truly ambitious provisions. It is just about as narrowly tailored as an Obamacare stabilization bill offered by Democrats could be, a fact that aides and activists will privately concede.

Missing are any of the bolder policy proposals animating the left. Not even a hint of Medicare-for-all single-payer health care, which is or isn’t a surprise, depending on how you look at it.

Medicare-for-all is quickly becoming orthodoxy among many in the party’s progressive grassroots, and a single-payer bill proposed this Congress in the House (similar to the one offered by Bernie Sanders over in the Senate) has 123 sponsors.

But House Democratic leaders probably don’t want to take up such a potentially explosive issue too soon after finally clawing back a modicum of power in Trump’s Washington.

Still, the current stabilization bill doesn’t even include a Medicare or Medicaid buy-in, the rebranded public option that never made it into Obamacare but would allow Americans to voluntarily join one of the major government insurance programs. It is an idea that even the more moderate Democratic members tend to support, and polls have found three-fourths of Americans think a Medicare buy-in is a good idea.

The plain truth is House Democrats haven’t reached a consensus yet about what they want to do to cover more Americans. They agree Obamacare was an important first step, and they agree the status quo is unacceptable. But the exact mechanism for achieving those goals — single-payer, a robust public option, or simply a buffed-up version of Obamacare — is still very much up for debate.

“People will want to do something, but any further action is going to be a consensus-building process,” a senior House Democratic aide told me. “Democrats have lots of different ideas on how to continue working to reduce the uninsured.”

That is all well and good, but few issues are exciting the Democratic grassroots right now like Medicare-for-all. During the midterm campaigns, Democratic candidates and even grassroots leaders were happy to let those words mean whatever voters wanted them to mean. For some people, it meant single-payer; for others; it might mean a Medicare buy-in or something more limited.

The unreservedly progressive members who were just elected to Congress will only wait so long before they start pressing Democratic leaders to take more aggressive steps to pick up one of their top campaign issues. That pressure will only intensify as the 2020 presidential campaign heats up and Democrats debate what kind of platform they should run on as they seek to take back the White House.

For now, Democrats have tried to put off a difficult debate and focus on what unites them. But the debate is still coming.

The riddle of high drug prices still needs to be solved too

Even with Obamacare and preexisting conditions mobilizing Democratic voters this year, prescription drug prices remain a top concern for many Americans. That’s another area where Democrats know they want to act but don’t know yet exactly what they can or should do.

The issue could be an opening for serious dealmaking: Trump himself has attacked big pharma since his presidential campaign. His administration has actually launched some interesting initiatives to rein in drug costs — approving a record number of generic drugs, trying to even the playing field between America and foreign countries — that have some policy wonks intrigued, even if the impact is still to be determined.

Democrats have mostly stuck to slamming Trump for feigning to act on drug prices while cozying up to the drug industry. But it’s a top priority for both parties, and there could be some room for compromise. One progressive policy wonk thought a drug prices bill might actually be the first Democratic priority. It helps that drug prices are a populist issue that the new House majority might really be able to pass a bill on.

But first, Democrats have to figure out what exactly they are for — and what would actually make a difference.

The rallying cry for Democrats on drug prices has been letting Medicare directly negotiate prices with drug manufacturers, a proposal that Trump also embraced as a candidate, though he has since softened as president. The problem is the Congressional Budget Office doesn’t think Medicare negotiations would save any money unless the government is willing to deny seniors coverage for certain medications. But adding such a provision would surely invite attacks that Democrats are depriving people’s grandparents of the medications they need.

There are a lot of levers to pull to try to reduce drug prices: the patent protections that pharma companies receive for new drugs, the mandated discounts when the government buys drugs for Medicare and Medicaid, existing hurdles to getting generic drugs approved, the tax treatment of drug research and development. Lawmakers and the public view pharmacy benefits managers, the mysterious middlemen between health insurers and drugmakers, skeptically.

But none of those are silver bullets to lower prices, and they will certainly invite pushback from the politically potent pharmaceutical lobby, focused on the concerns about how much cracking down on drug companies to discourage them from developing new drugs. Democrats also don’t know yet what specific policies could win support from Senate Republicans or the Trump White House.

“How do you take this gargantuan Chinese menu of things and figure out how things fit together in a way that stem some of the abuses?” is how one Democratic aide summarized the dilemma.

It is a problem bedeviling Democrats on more than just drug prices. Health care was a winner on election night this year, and it has always been a priority for Democrats. Now they just need to figure out what to do.

Because tomorrow is Veterans Day I thought that I would include this article.             After A Year Of Turmoil, New VA Secretary Says ‘Waters Are Calmer’ 

Quil Lawrence in his Twitter post reported on a wide-ranging interview with NPR, Secretary of Veterans Affairs Robert Wilkie said his department is on the mend after a tumultuous 2018.”I do think it is better because the turmoil of the first half of this year is behind us, the waters are calmer. We’re not where we need to be, but we’re heading in that direction,” he said.

Early in Donald Trump’s presidency, the VA was considered an island of stability in an unpredictable administration.

Secretary David Shulkin was a hold-over from the Obama administration, already familiar with the VA’s massive bureaucracy. Bipartisan reforms moved through Congress with relative speed, and Trump could point to a list of legislative accomplishments.

But the president fired Shulkin last March after weeks of intrigue during which VA political appointees plotted openly to oust him. Trump’s first nominee to replace Shulkin, Rear Adm. Ronny L. Jackson, sank under accusations of misconduct (which are still being investigated by the Pentagon).

Numerous high-ranking officials left the department, and records showed that friends of the president outside of government – who weren’t even veterans – had been lobbying Trump at Mar-a-Lago on how to run the VA.

After a stint as acting VA secretary, Robert Wilkie was confirmed by the Senate last July. Since then, Wilkie says he’s been “walking the post,” visiting as many VA facilities as he can. And he’s reached the same conclusion as many of his predecessors.

“I have been incredibly impressed by the caliber of VA employee I’ve encountered everywhere, from Alaska to Massachusetts to Florida,” Wilkie told NPR’s, Steve Inskeep.

“I have no quarrel with the quality of medical care our veterans receive. My biggest problem is actually getting them into the system so that they can receive that care, which means the problems are primarily administrative and bureaucratic,” said Wilkie, himself a veteran of the Navy and a current Air Force reservist, who counts generations of veterans in his family.

“I am the son of a Vietnam soldier. I know what happened when those men and women came home,” Wilkie said. “So that is incredibly important to me.”

Wilkie is navigating an important moment for the VA – while Congress has already passed major reforms, he’s the one who has to implement them. And plenty of political controversy hides in the details.

The VA Mission Act of 2018 was signed into law in June. It’s intended to consolidate about a half-dozen programs The VA uses to buy veterans private healthcare at a cost of billions of dollars, into one streamlined system.

Critics fear that leaning too much on private care will bleed the VA’s own medical centers, and lead to a drop in quality there – and amounts to a starve-the-beast strategy of privatization.

Wilkie says that won’t happen and is not President Trump’s goal, but he has yet to present a budget for expanded private care to the White House and to Congress.

“You’re not going to privatize this institution. I certainly have never talked about that with anyone in this administration,” Wilkie said.

Wilkie also maintains that he has had little contact with the group of outside advisers who meet with the president at Mar-a-Lago, including CEO of Marvel Comics Ike Perlmutter and Florida doctor Bruce Moscowitz. Records show they had extensive communication with the previous VA secretary, sometimes influencing policy decisions.

“I met with them when I was visiting the West Palm Beach VA – my first week as acting (secretary), and have not had any meetings with them ever since that day,” Wilkie said. “I’ll be clear. I make the decisions here at the department, in support of the vision of the president.”

Despite rumors that Wilkie would clear out many of the Trump political appointees who clashed with former secretary Shulkin, he said he didn’t expect more staffing changes.

The one notable departure is Peter O’Rourke, who was acting secretary for two months while Wilkie went through the confirmation process. O’Rourke clashed repeatedly with Congress and the VA’s inspector general. Wilkie himself cited a Wall Street Journal reports that O’Rourke is poised to go and said he’s “on leave.”

“I think there will be an announcement soon about a move to another department in the federal government – I know that he’s looking for something new,” said Wilkie, “He’s on leave.”

Another major new plan that Wilkie must implement is a $10 billion, 10-year plan to make the VA’s medical records compatible with the Pentagon’s.

He once again mentioned his father’s experience as a wounded combat vet.

“He had an 800-page record, and it was the only copy, that he had to carry with him for the rest of his life. He passed away last year,” said Wilkie.

“One of the first decisions I made as the acting secretary was to begin the process of creating a complete electronic healthcare record that begins when that young American enters the military entrance processing station to the time that that soldier, sailor, airman, Marine walks into the VA.”

But that process has actually been underway for a decade – with little to show and about a billion dollars already spent on the effort. The non-partisan Government Accountability Office says it’s in part because neither the Pentagon nor the VA was put in charge of the effort — which is still the case. Wilkie says he has signed an agreement with the Pentagon to jointly run it with clear lines of authority.

“I think we’ll have more announcements later in the year when it comes to one belly-button to push for that office,” he said.

As for staff shortages, another perennial complaint at the VA, Wilkie acknowledged there are 35- to 40,000 vacancies at the agency.

“We suffer from the same shortages that the private sector and other public health services suffer from, particularly in the area of mental health,” he said.

New legislation passed this year gives Wilkie the authority to offer higher pay to medical professionals.

“I’m using it to attract as many people as we can into the system,” said Wilkie

But Wilkie also added that he was shocked, upon taking the post, that it’s not clear how many additional people are needed – because it’s not even clear how many people are working at VA.

“I had two briefings on the same day and two different numbers as to how many people this agency employs.”

Wilkie says he’s in the process of finding out the answer to that question, and many others, as he starts his second 100 days in office.

And to end this post I must include this note. I was raised in the Bronx, New York and are truly embarrassed to acknowledge that the new Congresswoman Cortes-Ortes who was elected, and not sure how when you look at her qualifications and knowledge. But more, she is a socialist and expects everything to be given to all and the government will foot the bill and now listen to this.

Alexandria Ocasio-Cortez, new youngest Congresswoman, says she can’t afford D.C. apartment

Ashley May, a reporter for the USA TODAY noted that the upset primary win in New York by Alexandria Ocasio-Cortez is a huge moment for the Democratic Party because it shows the left-wing base is energized heading into the midterms, according to AP National Politics Reporter Steve Peoples. (June 27) AP

Alexandria Ocasio-Cortez, the youngest woman elected to Congress in the midterm elections, is struggling to pay rent, according to a recent interview.

Ocasio-Cortez, 29, told The New York Times she’s not sure how she will be able to afford an apartment in Washington, D.C., without a salary for three months in an interview published online Wednesday.

She told the Times she has some savings from her job earlier this year as a bartender at a Union Square restaurant, and she’s hoping that will hold her over. Living without a paycheck is something she said her and her partner tried to plan for, but it’s a hardship that’s still “very real.”

“We’re kind of just dealing with the logistics of it day by day, but I’ve really been just kind of squirreling away and then hoping that gets me to January,” she told the Times.

Ocasio-Cortez is a New York activist and Democrat who will represent the 14th Congressional district, which covers the Bronx and Queens.

Thursday, she pointed to her lack of income as a reason why some people are not able to work in politics.

“There are many little ways in which our electoral system isn’t even designed (nor prepared) for working-class people to lead,” she said.

She said she hopes she can change that.

Yes, and now if she plays her cards right she has a job, paying better than any job that she is really qualified for life.

Buck it up Ocasio-Cortez, live outside of DC and take public transportation like most people do!

How did you fund your campaign? I don’t want to hear your sob story and yes I am ashamed that the borough of the Bronx has you for their representative. What a joke! You said that when you got to DC you were going to sign a whole lot of bills and laws to make things better. Do you even know anything about the process and have you ever taken a Civics course. You are in for some big surprises… called reality!

On a better note-Happy Veterans Day and thank you all who have served in our military and those who are still out there helping to make this world a better place to live and protecting our freedoms.

 

State of Health: Boston Doc Sees State Rep Run as a Way to Help Patients. Healthcare and the Mid Terms and a Summary of the Issues

45112654_1770213053108346_4596023887606579200_nNow that the Mid Term elections are upon us I can honestly state that I am somewhat ambivalent regarding the outcome. I’m pretty sure that the Democrats are going to claim the majority in the House and maybe the Republicans will hold onto the Senate. But to what end. The fighting will go on and probably nothing will get done. The Republicans have no one to blame but themselves for losing the House majority. Where was their leadership and don’t point fingers at the President? His leadership roles could be questioned but the big issue is that leader Ryan, although I like him was no leader as well as so many Republican Congressmen and women deciding to retire at such an important time and therefore not supporting their President.

The Democrats have disgusted me with their horrible behavior and attacks and playing the blame game Their leadership just sickens me during these last 2 years and them look who we have to run for the Presidency, again members who truly have made things worse, not better and not even trying to negotiate, be civil and spouting lies and attacks. As I said both parties have sunken to new lows in their behavior. I wish that we did have a significant Third Party for whom I would vote for. Again it holds your nose and vote.

Our friend, Joyce Frieden the News Editor of MedPage reported that Healthcare is expected to be a major issue in the November election — not just in Congress but also in the states. With that in mind, MedPage Today is profiling several candidates for statewide office who are focusing on healthcare issues. In our third and final profile, we speak with Jon Santiago, MD (D), an emergency room physician who is running for the Massachusetts House of Representatives.

Jon Santiago, MD, saw it firsthand every day. “I work in an ER at Boston Medical Center and it’s a great job,” Santiago said in an interview with MedPage Today. “It’s a job I love in a hospital I’ve wanted to work at since I was a kid.”

Naturally, Santiago, a fourth-year emergency medicine resident, tackles difficult problems as an emergency physician — including gunshot wounds, strokes, and heart attacks. “I live for those exciting moments, but you begin to realize that working in an ER, you’re taking care of a lot of social issues — poverty, racism, sexism, and lack of economic opportunity or housing — that ultimately manifest in some kind of medical condition, and that’s when we treat them.”

“We’ll literally or figuratively put a Band-Aid on them … but it’s not until we solve the social determinants of health that we begin to [really] solve their problem,” he continued. “That’s why I decided to run for office.”

Opioid ‘Ground Zero’

As a public hospital, Boston Medical Center is “ground zero” for the opioid epidemic, both in the city and the state, Santiago said. He cited the example of Long Island, an island near Boston that houses a number of homeless shelters and recovery services. “There was a bridge to an island near Boston that overnight had to be shut down because it was dangerous, so in a matter of days, we had to move about 400 people into the [South End] neighborhood, many of whom were homeless and had substance use disorder. It really changed the community.”

In addition, for those people that had to be moved, “their continuity of care stopped, and as a result, people died … My run for office is really for these patients I take care of who need the help, but also for significant quality-of-life issues in the community.”

Santiago noted that with its many world-class healthcare facilities, Boston is considered the “healthcare capital of the state, if not the country and the world.” But the state also has its own healthcare challenges — Massachusetts’ Medicaid program, known as MassHealth, takes up 40% of the state budget. “And Massachusetts likes to pride itself that we were the first to pass health care reform, providing universal coverage, but that doesn’t mean healthcare is affordable or accessible.”

For example, “MassHealth doesn’t cover everything; there is always talk of cutting certain services,” said Santiago. “Just this past year, the governor threatened to knock out about 140,000 people from MassHealth to save money.”

Technically, the coverage rate in the state is 97%, but “the question is, if you look at what people pay for the administration of private healthcare, the costs are significantly more than a public provider would have,” he said, noting that Medicare’s administrative cost is about 10%. “Other developed countries are able to provide more cost-effective healthcare with … better outcomes.”

Santiago supports single-payer universal health care coverage for all state residents through a “Medicare for all” system. The first step toward that goal, he said, would be to study single-payer and compare the current system to what single-payer would look like “and if it would save money, I would pursue that because what we have is not really sustainable.”

An Unlikely Winner

Santiago was an unlikely winner in the Democratic primary race in his district. “I beat a 36-year incumbent who was the majority leader, the fourth highest-ranking person in the state,” he said. “What people were looking for [was] people to provide political leadership on issues that matter, and when it comes to the opioid epidemic, people were looking for solutions.” Santiago attributes his victory to a very grassroots strategy. “I personally knocked on 8,000 doors; we knocked on every door in the district. If you talk to people and listen to them, you’re better able to serve their needs.”

“The person representing this district — the center of the epidemic — should be a leader on this issue,” he continued. “Massachusetts Avenue they call the ‘Methadone Mile’ here; I live close to that. The Boston Medical Center emergency department is located there, and as an emergency department provider, it gives me initial insight into what is going on, on the ground.”

He gave an example of how, 3 years ago, his experience helped him change the law. “In my first year as a doctor, with the prescription drug monitoring program (PDMP), if someone comes in with back pain, you check to see whether they have previously been given an opioid prescription — if they have, it’s a red flag. I tried to look [at the PDMP] during my first year as a doctor, and I couldn’t access the website. I turned to my attending and he said, ‘Only attendings can.'”

But since the residents do much of the work at the hospital, “I said, ‘This doesn’t make sense,'” said Santiago. “I got the doctors together and we started a petition to provide access [to the PDMP] to the residents who do all the work. I got the petition started, met with the Boston Globe, and they covered it; we met with the governor’s staff and they changed the law overnight. Within a week or so, residents across the state were able to access the PDMP.”

Post-Election Plans

If Santiago wins the election, “my plan is to continue working as an ER doctor because I think one job really informs the other,” he said. “One job really keeps you close to the community and the issues neighbors face day in and day out, and working as a state representative addresses those issues in the policy arena.” A total of 14 8-hour shifts per month are considered full-time; Santiago said he planned to work one to two shifts a week during the legislative session, “and I’d be the only physician [legislator] in the capital as well.”

Public service is nothing new to Santiago, who served as a Peace Corps volunteer in the Dominican Republic and is currently a captain in the Army Reserve. “I graduated from college and wanted to join the military, but I was not enthusiastic about the Iraq War,” he explained. “I wanted to serve my country, so I joined the Peace Corps … I told myself that if I became a doctor I would join the Army Reserve so I could serve in that capacity.” The reserves are pretty flexible since they only require one weekend a month and 2 weeks a year, and if you do deploy it’s only for 3 months, he added. “But they’re very flexible with you if you’re a doctor.”

In Trump midterms, one GOP congressman bets re-election on healthcare

Reporter Susannah Luthi noted that Rep. Peter Roskam (R-Ill.), in the final sprint for his congressional life, wants to talk about Medicare red tape. The message is a big deal in his hospital-dominated district that headquarters the state’s largest system, Advocate Health Care. His health subcommittee chairmanship for the powerful House Ways and Means Committee positions him to push measures that resonate when hospitals attribute 25% of their spending, or about $200 billion per year, to paperwork.

But while policy specifics may matter for his committee work and for the business of healthcare, analysts are skeptical they can prevail over the “Trump effect”—widespread rejection of the president by moderate suburban Republicans, which makes elections in places like the Illinois 6th District a national more than a local referendum.

Roskam now lags in the polls behind his Democratic challenger Sean Casten, a clean energy entrepreneur who has harnessed local opposition to President Donald Trump to pull ahead of a six-term congressman of a district that was designed as a GOP stronghold.

Questioning the 80/20 rule for healthcare

The 80/20 rule in health care underlies much of the common thinking about population health. Many value-based strategies about health care costs or utilization use this rule to describe the distribution of health care spending. Is the 80/20 rule accurate today? We analyzed recent data to find out.

He’s also struggling to make another national healthcare message local.

The term “pre-existing conditions” is headlining the cycle. The tagline has become particularly effective in light of the GOP state attorneys general lawsuit to strike down the Affordable Care Act. The Trump administration sided with the lawsuit, specifically asking the courts to overturn the provisions around community rating and other cover requirements that prohibit insurers from charging more for people with expensive, pre-existing conditions.

Roskam voted with most of his party for the GOP effort to repeal and replace the ACA, and Casten has been pounding him for it.

But on a rainy Friday in early October, as he toggled between campaign events and representational duties that involved a deep dive into CMS pay rules for disabled adults in the community, Roskam stuck with his policy line. He said this still matters in what he described as his “solution-oriented” district.

“My observation is that if the ACA were doing what it’s purported to do, the district wouldn’t be restless and they’d be quick to turn the page,” Roskam said. “But they are restless and there is a sense of vulnerability that’s out there and it’s largely financial.”

Then he pivoted to what he has been working on as a congressman: the Medicare Red Tape Relief project that culminated in a report late this summer, which he believes is more relevant for bringing costs down.

“The country feels stuck in a debate [over Obamacare] and it’s ready to get out of the ditch of the debate,” Roskam said. “It’s well litigated where both sides are on the ACA. And these continuous declarations—most people don’t find a level of connection. Which is why the red-tape relief effort resonates. ‘Yes, I get that, my doctor is looking at a screen half the time he’s with me. That’s not the way it used to be.'”

But that’s not the focus in this race. After millions of dollars in advertising from both sides, Roskam is trailing by five points in the latest FiveThirtyEight poll. The nonpartisan Cook Political Report rates the race as “lean Democratic” as Casten pummels Roskam’s record of voting 94% of the time for Trump’s agenda.

The flip is emblematic of what’s happening in moderate suburbs that voted for Hillary Clinton in 2016, said David Wasserman, House editor of Cook Political Report. That’s when Roskam cruised to a double-digit victory even though Clinton beat Trump by seven points in his district.

Casten, whose core issue is climate change, wasn’t necessarily the strongest Democratic candidate for the district, Wasserman added. He wasn’t the favorite in his primary and even Democratic strategists complain about his bombastic style. But none of this may matter.

“Roskam has failed to make the race a referendum on Casten, and it’s become about Trump and Roskam,” Wasserman said.

In Roskam’s case, there are also state-based headwinds: a deeply unpopular GOP governor who is motivating Democratic voters in the state, and a GOP president who is unpopular in a prosperous GOP district.

“If Peter wins, it’s because people are willing to look at him as someone who is independent of Trump and has been a good representative of the district,” a longtime GOP Illinois strategist said.

At a Casten sit-down with local members of the Illinois Alliance for Retired Americans as the group endorsed him, the dissatisfaction with healthcare played out in condemnations of Roskam’s 2017 vote to repeal the ACA. They talked about denials of care by insurers through pre-authorizations they didn’t understand, their fears about the future of coverage for pre-existing conditions, and Medicare’s solvency.

Kim Johnson, a retired state worker who is taking care of two of her grandchildren, said that one granddaughter was born with a heart condition and blasted Roskam for his 2017 vote saying that if he “had his way, she’ll have no insurance.”

But the status quo is also not enough, Johnson added, noting that she wants to see “universal healthcare.”

“I just want to see something,” she said. “I want to see something improve. We are a much better country than what our benefits are.”

Casten reiterated his support for the ACA and said he wants to look at a public option through an expansion of Medicare or Medicaid or both.

But he has steered clear of the more progressive Democratic positions. He criticized the Medicare for All proposal of Sen. Bernie Sanders (I-Vt.) as “irresponsible” and said it made him nervous. At the table of retirees, Casten also defended the for-profit nature of the U.S. system, which he said drives the right incentives for efficiency.

He has also drawn a hard line about what he thinks about Republicans, and about working with them. “On almost everything we are arguing about, there are no areas for compromise,” specifically on the confirmation of Justice Brett Kavanaugh to the Supreme Court, climate change and voting rights, Casten told a group of nursing home residents in one event.

Roskam recently ranked as the 25th most bipartisan House member out of 435 lawmakers, is banking on his district rejecting that approach. Issues like Medicare fraud and Medicare solvency matter, he said, but big policy pushes need buy-in from both Democrats and Republicans and work needs to be incremental.

Roskam has blasted Casten’s campaign speech—and his active Twitter feed—as Trump-like. But in the last stretch of the race, the rhetoric has intensified, thanks to the millions of dollars raised for ads that are barraging the district and even its surrounding counties. Campaign signs blanket lawns and the roads connecting this leafy, prosperous district.

James, a nursing home resident who had attended Casten’s event there and who declined to give his last name, said that what he will be watching for this election is what it will say about voters’ views of Trump.

“Are people catching on with what Trump is doing?” James said. “Everybody’s got a right to vote—that’s a good thing and a bad thing. Hopefully, people will catch on to what’s going on.”

Healthcare and the midterms: I’ve got you covered

Healthcare is top of mind for many 2018 midterm voters. As they select state and federal representatives, many ballots also include measures for Medicaid expansion, provider pay and other key healthcare issues. Federal policy on the future of the Affordable Care Act, drug prices and immigration reform will also affect the healthcare industry. I thought that I would use this article to summarize the MidTerm issues.

Modern Healthcare has been tracking how policy changes and discussion could affect the midterm elections. A change in House or Senate party control or governors’ races can tilt the scale on many hotly contested healthcare issues. Here we’ve rounded up our coverage on the upcoming midterm election.

Midterm elections 2018 at a glance

2018 elections: The future of healthcare could be purple: In the lead-up to the midterms, Democrats appear poised for gains in Republican-controlled legislatures and governor’s mansions, which could push the states to make the healthcare compromises that Washington can’t.

In Trump midterms, one GOP congressman bets re-election on healthcare: In an intense congressional race in the Chicago suburbs, hospital ally Rep. Peter Roskam (R-Ill.) is running on an anti-regulatory healthcare message. But in a referendum election about Trump, how will that play?

The 115th Congress on the State of Healthcare: Modern Healthcare’s 115th Congress on the State of Healthcare is a featured collection of commentaries from lawmakers and healthcare organization leaders. Included in this collection of Congressional commentaries are six editorials from U.S. Senators and eight House Representatives across both party lines.

Data Points: Healthcare tops the polls as midterms loom: The all-important 2018 midterm elections are less than two months away. As special elections and primaries, this summer has proven, healthcare continues to be a hot-button issue.

Editorial: Healthcare PACs voting for incumbent protection: Many Democratic congressional hopefuls are making healthcare their top talking point for the upcoming midterm elections, which is not surprising given the low unemployment rate. The early donations from political action groups lean toward the incumbents.

House Speaker Ryan to retire with a mixed legacy on health policy: House Speaker Paul Ryan’s upcoming retirement from Congress after leading the GOP’s charge to repeal the Affordable Care Act leaves his party in a challenging place on health care messaging ahead of the 2018 midterm elections.

Status of Medicaid expansion states and work requirements

Bullish post-election Medicaid expansion outlook may not match end result: Although a new report predicts 2.7 million people in nine states could soon become eligible for Medicaid, expansion could look very different state by state.

Medicaid expansion on the prairie: Nebraska’s ballot initiative heads to the polls: Four years into Obamacare, the majority of Nebraska voters support Medicaid expansion, a key measure on their midterm ballot. But even pro-expansion hospitals are taking a cautious view of how much it will impact the rural bottom line.

Verma touts Medicaid work requirement successes, despite coverage loss: CMS Administrator Seema Verma insisted that Medicaid work requirements are working as intended to move people out of poverty, despite criticism that they’re doing more harm than good.

Medicaid blues: Hospitals, insurers wage a political battle over managed-care dollars: Medicaid, the 50-year-old federal-state health coverage plan for the poor, has devolved into a political inter-industry feud in the impoverished Mississippi Delta. What does the fight foretell about the Medicaid industry and how it treats the nation’s poorest?

Could deep-red Miss. expand Medicaid? 2019 will tell: A Mississippi state senator has introduced a bill to expand Medicaid every year since Obamacare went into effect, but so far it’s been off the table. The 2019 governor’s race could change the picture.

Close governor races could decide future of Medicaid: Advocates say the single biggest factor in expanding Medicaid in balky states has been the election of a governor who supports it.

Editorial: Want people off Medicaid? Give them more access to it: New research found those who gained coverage through Michigan’s Medicaid expansion faced fewer debt problems, fewer evictions, and bankruptcies, and saw their credit scores rise just years after enrolling for coverage.

Wisconsin can impose Medicaid work requirements, time limits, but not drug testing: The CMS on Wednesday gave Wisconsin permission to impose work requirements on beneficiaries. It’s the first state to receive a green light for the policy without expanding Medicaid. The agency rejected the state’s mandatory drug testing proposal.

Tennessee joins push for Medicaid work requirements: Tennessee is the fourth state this month to introduce a work requirement proposal for its Medicaid enrollees. Officials there believe it has a better chance of CMS approval than other non-expansion states due to its coverage policies for adults.

House Democrats press HHS for Medicaid work requirement records: Two top Democrats on the House Oversight Committee want to subpoena the Trump administration’s documents around its Medicaid work requirement policy. HHS officials haven’t responded to their previous requests for information.

Healthcare reform issues

Senate Dems fail to block Trump’s policy on short-term health insurance: Wisconsin Democrat Sen. Tammy Baldwin’s forced vote to overturn the Trump administration’s plan for short-term health insurance failed in a tie, although the Democrats gained one Republican ally.

Senate Republicans in talks with Verma to expedite states’ 1332 waivers: The Senate’s two top GOP proponents for individual market exchange stabilization measures are in talks with CMS Administrator Seema Verma about making 1332 state innovation waivers easier to obtain.

Affordable Care Act:

Editorial: The midterm elections will decide the fate of the ACA: If the GOP maintains control of the entire government, the nation’s health insurance marketplace would look a lot like the one that existed before passage of the Affordable Care Act.

Judge skeptical of ACA’s standing without effective individual mandate penalty: In a U.S. district court Wednesday, a federal judge had hard questions for Democratic state attorneys general who argued that the ACA can stand even with a zeroed-out tax penalty.

ACA court case causing jitters in D.C. and beyond: A lawsuit aiming to overturn the Affordable Care Act goes before a conservative Texas judge Sept. 5. The health insurance industry and GOP lawmakers are bracing for the potential fallout.

Uncertainty could spook insurance markets as DOJ decides not to defend ACA: The Department of Justice has asked a federal court to invalidate three key Obamacare coverage mandates, siding with a red state lawsuit against the Affordable Care Act and spurring new uncertainty for the 2019 individual market.

Republicans weigh electoral calculus on reviving ACA repeal push: Both Republican and Democratic political observers see a narrow possibility for yet another Obamacare repeal drive this year, given intense pressure from conservatives and the urgent GOP need to fire up right-wing voters to maintain their control of Congress in this fall’s elections.

Pre-existing conditions:

Pre-existing conditions drive state attorney general campaigns: Democratic candidates in state attorney general races have leveraged their party’s national campaign strategy around coverage of pre-existing conditions. They’re trying to beat Republican incumbents who are suing to end Obamacare.

Will Republicans keep their new promises on pre-existing condition protections?: Despite congressional GOP candidates’ promises, health policy analysts doubt whether victorious Republicans would move to replace those ACA protections with equally strong measures to cover people with health conditions as part of repeal legislation.

Tight Iowa congressional races key on pre-existing condition protections: The battle over pre-existing condition protections has become particularly heated in two toss-up House races in Iowa, even as unregulated Farm Bureau health plans that can use medical underwriting will go on sale Nov. 1.

GOP senators propose new protections for challenged ACA provisions: As the country heads toward midterm elections and red states look to overturn Obamacare in the courts, Republican senators have introduced a bill to preserve some of the law’s most popular provisions.

Medicare for all:

Verma argues ‘Medicare for all’ would cause physician shortage: In a speech to insurers, CMS Administrator Seema Verma claimed patients would struggle to find a doctor if the U.S. implements “Medicare for all.”

‘Medicare for all’ proves to be a tricky issue for Democrats: Progressive Democrats want to wrestle “Medicare for all” into their party’s platform. But Democratic strategists and the results of recent primaries say the country isn’t ready for it yet.

Drug prices in America

Editorial: Drug price controls? A good idea, but don’t bet on it: Once the heat of the campaign dissipates, a majority in both parties will remain susceptible to their main argument that high prices are necessary to promote innovation.

The fate of Trump’s Part B drug cost plan may depend on the Dems winning House: Trump’s Medicare Part B drug cost plan could move forward, particularly if Democrats win control of the House.

New CMS pay model targets soaring drug prices: The Trump administration’s first mandatory CMS pay model is projected to save taxpayers and patients $17.2 billion over five years by shifting Medicare Part B drugs to price levels more closely aligned with what other countries pay.

340B showdown: Big pharma, hospitals squaring off in lobbying fight: Hospitals have adopted a take-no-prisoners approach in the fight with Big Pharma over the 340B drug discount program. Can this strategy hold as Congress, oversight agencies, the courts and the Trump administration ratchet up scrutiny of the program?

Midterms 2018 ballot measures

Editorial: Medicaid expansion, dialysis, staffing ratios get grassroots push: Grassroots activism is behind both good and bad trends in policy. Consumer coalitions are behind Medicaid expansion ballot measures in several states, while other coalitions are pinpointing dialysis policy and staffing ratios.

Nurse-to-patient staffing ratios in Massachusetts

Mandated nurse-to-patient ratios spark high costs, few savings: Massachusetts voters in November will determine whether mandated staffing ratios for registered nurses will go into effect Jan. 1. Implementing the ratios could cost providers $676 million to $949 million per year.

Data Points: A state-by-state look at nurse-to-patient staffing ratios: As nurse-to-patient ratios are debated on both coasts, projections show a few states may not be able to meet future demand for registered nurses.

Dialysis ballot measure in California:

Dialysis Cos. dole out more than $100M to beat Calif. ballot measure: With just a few weeks to go until November’s elections, the dialysis industry has raised more than $105 million to defeat a ballot measure that would cap their profits at 15% of direct patient-care costs.

Calif. governor vetoes dialysis reimbursement cap: Dialysis giants DaVita and Fresenius won a major victory in California as Democratic Gov. Jerry Brown vetoed a bill that would have slashed and capped their reimbursement rates.

Impact of immigration on healthcare

Children’s hospitals bear the largest brunt of Trump immigration crackdown: Children’s hospitals could see their revenue dip if increased anti-immigration sentiment from the Trump administration causes an exodus from Medicaid. Chronically ill children on Medicaid primarily go to these facilities for their hospital stays.

Clinics catering to immigrants take a hit from White House policy: Healthcare providers who care for refugees are faced with the financial strain of having fewer new patients as a result of the Trump administration’s limits on immigration.

Healthcare groups blast proposed rule penalizing immigrants for using public benefits: The Department of Homeland Security published a proposed rule that would allow immigration officials to consider legal immigrants’ use of public health insurance, nutrition and other programs as a strongly negative factor when applying for legal permanent residency.

Immigrant detention crisis could yield a profit for some providers and payers: The influx of immigrant children under HHS’ care translates into big contracts for providers charged with the children’s medical treatment.

Trump’s immigrant healthcare rule could hurt low-income populations: The Trump administration reportedly is nearing completion of a new immigration rule that health care providers and plans fear will harm public health and their ability to serve millions of low-income children and families.

What do U.S. immigration policies mean for the healthcare workforce?:

There’s been a drop in the number of foreign-born medical graduates applying for residencies in the U.S. at the same time that the country struggles with physician staffing shortages. Industry stakeholders worry the decline comes from recent efforts to stem immigration.

So, everybody hold your noses, do your research and VOTE! We’ll see what happens Tuesday!

Republican Doublespeak on Health Care Starts at the Top, And now Uber Finds a Way to get into the Healthcare Business-Ha, ​Ha!!

44342794_1752462594883392_1210998589254270976_nMax Nisen for Bloomberg noted that as much as one may not like Obamacare and the sustainability of the system one must appreciate the need for the pre-existing conditions issues. This issue n most insurance policies makes it unaffordable for patients and an out for the insurance companies who always are making money.Untitled.preconditions.1

Republican Doublespeak on Health Care Starts at the Top

(Bloomberg Opinion) — If anyone needed more evidence that Republicans are nervous about health care’s impact on this year’s midterm elections, the president provided it Thursday afternoon.

All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support. Also, Democrats will destroy your Medicare, and I will keep it healthy and well!

In the real world, President Donald Trump’s Justice Department is arguing in court that the Affordable Care Act’s protections for pre-existing medical conditions are unconstitutional and should be nullified. On top of that, his administration explicitly supported a bill passed by House Republicans that would have weakened those protections.

Senate Majority Leader Mitch McConnell is also trying to have it both ways, claiming this week that Republican Senators universally support protecting people with pre-existing conditions, while voicing his support for the lawsuit and another repeal effort.

Democrats recognize that the GOP is vulnerable and conflicted on health care, and its candidates are devoting millions of dollars worth of ads to it. It’s not the only thing helping to give Democrats a strong chance of taking back the House. But it’s a key driver.

Trump and Senator McConnell are far from alone in touting their support for protecting pre-existing conditions while having voted or worked to dismantle the ACA. Many other candidates are doing the same tap dance, and are even running ads touting their support for the policy. The GOP candidates for Senate in tight races in Missouri and West Virginia are current attorneys general who is supporting the controversial lawsuit.

It’s easy to see why everybody’s anxious. The ACA’s robust protections for people with pre-existing conditions are highly popular. In a recent Kaiser Family Foundation poll, more than 70 percent of Americans agreed that it was “very important” that they remain law.

That gets at the heart of Republicans’ dilemma: It’s one thing to promise an end to Obamacare’s burdensome regulations while vowing to lower premiums and maintain patient protections. But it’s actually a phenomenally difficult policy problem, and the GOP hasn’t offered a proposal that solves it.

The ACA prohibits insurers from denying coverage to people with pre-existing conditions and from charging them more for it, ensures that all plans cover a core roster of benefits including mental-health treatment and maternity care, and bans lifetime and annual coverage limits. It supports those protections and insurers by attempting to create a large risk pool and subsidizing insurance for people with lower incomes.

If you cut out any part of that, the door likely opens for insurers to offer skimpier insurance, siphon off healthy people, and leave those with pre-existing conditions with less appealing or more expensive options. The administration is currently doing that on a smaller level by pushing cheaper but less comprehensive short-term insurance plans.

It’s theoretically possible to protect people with pre-existing conditions in other ways. But they almost certainly involve trade-offs. The one that the GOP has generally tended to favor recently is weakening protections for people with pre-existing conditions in order to lower costs for healthy people.

No GOP candidate wants to say that out loud, to admit that their definition of protection is different and less comprehensive than the status quo. Democrats are spending a lot of money to make the distinction clear.

Pre-existing conditions aren’t the only health-care sore spots for the GOP.

In past years, Republicans have run on the idea that Obamacare’s individual market is an irredeemable failure, bolstered by soaring premiums. But premiums have stabilized or declined and insurers are increasingly profitable, making it more difficult to assail the law. Premiums would be lower if the GOP hadn’t spent years deliberately undermining the market.

And referendums on the law’s Medicaid expansion, which has dramatically expanded coverage for vulnerable Americans in more than 30 states, are on the ballot in Utah, Nebraska, and Idaho. It’s implicitly on the ballot in others, where changes in the composition of state governments could push states toward expansion, or in the other direction toward Arkansas-style work requirements that push people off of the program.

If the House flips and Democrats hold Senate seats in West Virginia and Missouri, states that Donald Trump won by 42 and 19 points respectively, it’s a sign that the GOP needs to rethink its approach to health care.

Obamacare is finally working (and Republicans still want to kill it)

Rick Newman noted that President Trump might not mind if people starting calling Obamacare Trumpcare because the controversial health program signed into law in 2010 are finally stabilizing.

After several years of sharp rate hikes, insurance premiums for people participating in Affordable Care Act exchanges are actually due to fall in 2019. The Trump administration says the average premium for a typical plan will drop by 1.5% next year. That’s based on rates insurance companies must file with the states in which they operate. About 9 million Americans buy insurance on an ACA exchange.

“There’s been a lot of tumult under the ACA up till now,” says Larry Levitt, a senior vice president at the Kaiser Family Foundation. “But there’s no question it’s viable, in the face of significant headwinds. The ACA is embedded in the health care system.”

Insurance still isn’t cheap. The average monthly premium for a mid-level “silver” plan under the ACA will be $406 next year—69% higher than the average premium just three years ago. But steadier rates indicate that insurers have finally figured out how to properly price the policies sold on the exchanges. When the ACA first went into effect in 2014, insurers underpriced their plans. That forced them to impose sharp price hikes in subsequent years. The dramatic price swings might finally be over.

Most ACA participants receive subsidies that protect them from price hikes. But people who earn too much money to qualify for subsidies, and don’t get coverage through an employer, have gotten clobbered with soaring premiums in recent years. A married couple in their 50s can easily pay $25,000 per year in premiums alone. About 6.7 million Americans buy unsubsidized insurance on their own.

The stabilization of the ACA is actually an awkward development for Trump, who campaigned to repeal the law and has boasted that “piece by piece, Obamacare is just being wiped out.” Trump has tried to dismantle the ACA by cutting outreach and educational programs and killing reimbursements to insurance companies meant to cover the cost of low-income enrollees. Last year’s Republican-backed tax-cut bill killed the individual mandate requiring everybody to have health care coverage, effective at the start of 2019. That will probably reduce the number of people with coverage under the ACA.

More consumers approve of the ACA

Republicans, of course, came close to overturning the whole law last year—and may try again, if they retain control of Congress after this year’s midterm elections. Senate Majority Leader Mitch McConnell told Reuters recently, “if we had the votes, we’d do it.”

The public doesn’t actually want that, however. Approval of the ACA has gradually drifted up from a low of 33% right before the law went into effect in 2014, to 48% in the latest Kaiser Family Foundation poll. The disapproval rate was 40%, with 11% saying they don’t know. The law could get more popular once the individual mandate is formally gone since that was one of the law’s most controversial measures.

Health care is turning out to be a potent issue in this year’s midterm elections, with 71% of respondents saying in a Kaiser poll that it’s a “very important” factor in terms of who they will vote for. That’s more than any other issue. Jobs and the economy, normally the top concern, came in second, with 64% saying it’s very important.

Democrats think they have the edge on health care, since they generally support the ACA, along with provisions that would make it work better, such as measures to make insurance cheaper for people who don’t qualify for ACA subsidies. And many Democrats now support some version of the Bernie Sanders “Medicare for all” plan, which would extend the health program for seniors to others who don’t have coverage.

Trump, for his part, has allowed more narrow insurance plans, which were generally banned under the ACA, as a way to let some people pay less for less generous coverage. But Trump’s administration has also joined a lawsuit seeking to overturn one of the most popular parts of the ACA—a provision saying insurance companies cannot deny coverage or charge exorbitant fees to enrollees with pre-existing conditions. The details are complicated, but if Trump’s side wins, some states will probably go back to the old rules of allowing insurance companies to charge whatever they want. The politics of health care seems to have a lively future.

Aging undocumented immigrants pose costly health care challenge

Tersea Wiltz working for CNNMoney recently wrote that early on a recent morning, men huddle in the Home Depot parking lot, ground zero for day laborers on the hunt for work. Cars pull into the lot, and the men swarm.

Among them is Marcos, at 65, wiry and bronzed with a silvery smile. He’s been in the country illegally for 20 years. When he’s sick, he just rests, because — like most undocumented workers — he doesn’t have insurance.

“I don’t know if I have high blood pressure,” he said. “Because I don’t check. Doctors, you know, are expensive.”

For decades, the United States has struggled to deal with the health care needs of its undocumented immigrants — now an estimated 11 million — mainly through emergency room care and community health centers. But that struggle will evolve. As with the rest of America, the undocumented population is aging and developing the same health problems that plague other senior citizens.

Many undocumented adults lack health insurance, and even though they’re guaranteed emergency care, they often can’t get treated for chronic issues such as high blood pressure. What’s more, experts predict that many forgo preventive care, making chronic conditions worse — and more expensive to treat.

“They’re hosed. If you’re an undocumented immigrant, you’re paying into Social Security and Medicare, but can’t claim it,” said Steven Wallace of the UCLA Center for Health Policy Research.

When uninsured people end up in the hospital, that pushes up rates for those who have insurance. Or public programs like Emergency Medicaid pick up the tab. This contributes to a game of shifting costs, Wallace said.

“It’ll place a strain on the entire health care system,” Wallace said.

Growing numbers

Approximately 10% of the undocumented population is over 55 now, according to the Migration Policy Institute, but researchers agree that their numbers will rise.

“The unauthorized immigrant population has become more settled, and as a result is aging,” said Mark Hugo Lopez of the Pew Research Center.

Estimates vary on how many undocumented immigrants lack insurance. The Kaiser Foundation estimates 39 percent are uninsured, while the Migration Policy Institute, which analyzes U.S. Census data, estimates as many as 71 percent of undocumented adults do not have insurance.

Like Marcos, older undocumented people tend to be poor. The Affordable Care Act doesn’t cover them, and they don’t qualify for Medicaid, Medicare or Social Security, even though many pay taxes. Few can afford private insurance.

That means most must turn to emergency rooms or community health centers, which provide primary care to poor people, regardless of immigration status. But community health centers can’t provide extensive care, Wallace said. And because Congress has yet to fund them, their future is precarious.

Leighton Ku, professor, and director of the Center for Health Policy Research at George Washington University said immigrants, both authorized and unauthorized, are much less likely to use health care than are U.S. citizens. Until that is, they’re quite ill.

“Their numbers are going to grow and we’re going to have an epidemic on our hands,” said Maryland state Del. Joseline Peña-Melnyk, a Democrat. “Who’s going to pay for it?”

A 2014 report by the Texas Medical Association found that undocumented immigrants with kidney disease face considerable barriers to care. By the time they do get help, they need dialysis, costing Texas taxpayers as much as $10 million a year.

Stepping in to help

Many cities have tried to step in. A 2016 Wall Street Journal story noted that 25 counties with large undocumented populations provide some non-emergency health care to these immigrants, at a combined cost of what the paper estimated is more than $1 billion each year.

Washington, D.C., Los Angeles and San Francisco are among the places where undocumented immigrants can usually get routine care, thanks to locally funded programs.

In Los Angeles, Dr. Christina Hillson, a family practice doctor at the Eisner Health Clinic, said she’s seeing a growing number of elderly undocumented patients, whom she’s treated for everything from ovarian cancer to amputations resulting from untreated diabetes.

Patients who are critically ill are considered emergencies and can get treated at hospitals, she said. Sometimes Hillson will send patients who aren’t as ill to the ER because it’s the only way they can see a specialist.

Snapshot of a population

Most undocumented people immigrated here when they were young and tended to be healthier than native-born citizens, Wallace said. But as they age, they lose that advantage.

Undocumented women are more likely to have family in the U.S., who can help care for them as they age, said Randy Capps of the Migration Policy Institute. But men are more likely to be single. Because they often work as manual laborers, they’re more likely to get hurt on the job, Capps said.

“They’re going to age faster and become disabled at higher rates,” Capps said. “It’s going to make for a much tougher old age.”

There’s no one easy solution to helping older residents who live in the United States illegally, health and immigration experts say.

“The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem,” said Steven Camarota of the Center for Immigration Studies, which favors limiting immigration.

Joe Caldwell of the National Council on Aging, an advocacy group, said federal immigration legislation providing a pathway to citizenship would allow seniors to access care.

Such legislation is unlikely any time soon.

Outside the Home Depot, Marcos and his friends gather in the cold sunshine. He’s been paying taxes for years, Marcos said, and he’s got pages of documents to prove it. He’d love to become documented, “but that’s practically impossible,” he said.

A year ago, Marcos said, he had tightness in his chest. He had no choice but to go to the ER, but he hasn’t followed up. He’d rather stalk the parking lot here, looking for work.

“No work,” Marcos said, “no money.”

Uber Offers In-Hospital Patient Transport with UberGURNEY

I thought that we all needed to take a break from the serious depressing news around us and from this article from a satirical blog site and I hope that it will bring a smile to all. Uber’s success knows no bounds. After infiltrating cities across the world with their groundbreaking online-based transportation service, Uber “is” infiltrating hospital buildings with their new fleet of UberGURNEY vehicles, giving patients more options to get from point A to point B within a hospital. Wow, remember they already offer rides to your physician or clinic or even to your hospital as long as you don’t need special care. So is this the next step?!?UberGURNEY-e1476480255783“Look, we’ve conquered roads all over the world,” said Uber founder Travis Kalanick.  “What’s next?  The hospital corridors of the world.  Patients and nurses waste precious hours of their lives waiting for patient transport to arrive, whenever that is.  Not with UberGURNEY.  Just tap the app and we’ll pick you up.”

UberGURNEY does not require downloading a separate app, as UberGURNEY simply appears as another transport choice alongside UberPOOL, UberX, UberXL, and UberBLACK.  Trial runs conducted at Uber’s hometown hospital, the University of California at San Francisco, have garnered positive feedback.

Nurse Connie Jenkins explains.  “Endoscopy called me that my patient should be sent down.  I called for patient transport but no one picked up.  My patient had the Uber app, requested an UberGURNEY, and was picked up in 2 minutes.  It may not sound like much, but any minute shaved off for someone NPO can save a life.”  Jenkins is referring to an unfortunate incident earlier this year when a patient claimed he was starving to death after 1 hour NPO and actually died of hunger 1 hour later.

Feedback from patients has generally been positive as well.

“I really needed a turkey sandwich bad,” explained patient Ollie Nelson, rubbing his tummy with conviction.  “I gave UberGURNEY a whirl.  In three minutes, a driver picked me up and took me from my room to the cafeteria.  It was fantastic.”  Nelson did note one issue, however, a complaint about many long-time Uber users.  “After I ate my sandwich, it was like 5 PM.  Those surge prices are for real!  Fifty bucks just to get back to my room!  Maybe I should’ve walked.”

UberGURNEY will be rolling out in major academic institutions nationwide, including the Mayo Clinic, who revolutionized the transport game in 2014 with their pneumatic tube system for patient transport.  UberGURNEY is in its early stages but should it reproduce the success of its car service, Uber expects to offer an expanded fleet of UberGURNEYs with UberGURNEYBLACK for those who are willing to pay more for a private gurney and UberBODYBAG for those unfortunate patients who have died and wish to head to the morgue immediately.

Now imagine the self-driving cars picking you up and then transporting you around the hospital in driverless gurneys and our patients cared for by robot docs and nurses. Think about computer APPs and telemedicine, which is already here. Unbelievable!! Stay tuned!!

The Fiscal Burden of Illegal Immigration on United States Taxpayers including the Health Care System

44430232_1751281151668203_4321873792935657472_n-2I thought with the impending influx of the huge group of immigrants moving toward to the U.S. border, that we should look at the real impact. This is a fairly long post but one that “needs to be told”. Matt O’Brien and Spencer Raley reported on the continually growing population of illegal aliens, along with the federal government’s ineffective efforts to secure our borders, present significant national security and public safety threats to the United States. They also have a severely negative impact on the nation’s taxpayers at the local, state, and national levels. Illegal immigration costs Americans billions of dollars each year. Illegal aliens are net consumers of taxpayer-funded services and the limited taxes paid by some segments of the illegal alien population are, in no way, significant enough to offset the growing financial burdens imposed on U.S. taxpayers by massive numbers of uninvited guests. This study examines the fiscal impact of illegal aliens as reflected in both federal and state budgets.

The Number of Illegal Immigrants in the US

Estimating the fiscal burden of illegal immigration on the U.S. taxpayer depends on the size and characteristics of the illegal alien population. FAIR defines “illegal alien” as anyone who entered the United States without authorization and anyone who unlawfully remains once his/her authorization has expired. Unfortunately, the U.S. government has no central database containing information on the citizenship status of everyone lawfully present in the United States. The overall problem of estimating the illegal alien population is further complicated by the fact that the majority of available sources on immigration status rely on self-reported data. Given that illegal aliens have a motive to lie about their immigration status, in order to avoid discovery, the accuracy of these statistics is dubious, at best. All of the foregoing issues make it very difficult to assess the current illegal alien population of the United States.

However, FAIR now estimates that there are approximately 12.5 million illegal alien residents. This number uses FAIR’s previous estimates but adjusts for suspected changes in levels of unlawful migration, based on information available from the Department of Homeland Security, data available from other federal and state government agencies, and other research studies completed by reliable think tanks, universities, and other research organizations.

The Cost of Illegal Immigration to the United States

At the federal, state, and local levels, taxpayers shell out approximately $134.9 billion to cover the costs incurred by the presence of more than 12.5 million illegal aliens and about 4.2 million citizen children of illegal aliens. That amounts to a tax burden of approximately $8,075 per illegal alien family member and a total of $115,894,597,664. The total cost of illegal immigration to U.S. taxpayers is both staggering and crippling. In 2013, FAIR estimated the total cost to be approximately $113 billion. So, in less than four years, the cost has risen nearly $3 billion. This is a disturbing and unsustainable trend. The sections below will break down and further explain these numbers at the federal, state, and local levels.

Total Governmental Expenditures on Illegal Aliens

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Total Tax Contributions by Illegal Aliens

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Total Economic Impact of Illegal Immigration 

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The Federal government spends a net amount of $45.8 billion on illegal aliens and their U.S.-born children. This amount includes expenditures for public education, medical care, justice enforcement initiatives, welfare programs, and other miscellaneous costs. It also factors in the meager amount illegal aliens pay to the federal government in income, social security, Medicare and excise taxes.

FEDERAL SPENDING

The approximately $46 billion in federal expenditures attributable to illegal aliens is staggering. Assuming an illegal alien population of approximately 12.5 million illegal aliens and 4.2 million U.S.-born children of illegal aliens, that amounts to roughly $2,746 per illegal alien, per year. For the sake of comparison, the average American college student receives only $4,800 in federal student loans each year.

FAIR maintains that every concerned American citizen should be asking our government why, in a time of increasing costs and shrinking resources, is it spending such large amounts of money on individuals who have no right, nor authorization, to be in the United States? This is an especially important question in view of the fact that the illegal alien beneficiaries of American taxpayer largess offset very little of the enormous costs of their presence by the payment of taxes. Meanwhile, average Americans pay approximately 30% of their income in taxes.

Map: Illegal immigration costs California most, $23B, all states $89B

Now a break down of costs by state. Paul Bedford noted that the illegal immigration costs taxpayers in all 50 states a total of $89 billion, and California, where an illegal on Thursday was cleared of murdering Kate Steinle despite admitting to the shooting, pays the most at $23 billion, according to a new map of the costs.

The website HowMuch.net, working with figures from the Federation for American Immigration Reform, found that Californians pay more than twice as much for illegal immigrants than the next closest state, Texas, where the price tag is $11 billion.

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The costs cover added expenditures for education, welfare, law enforcement, and medical care.

When federal costs are included, the price tag nationally soars to $135 billion a year.

FAIR’s data also includes the offset of taxes paid by illegal immigrants, though the numbers are much lower. In the state and local column, they are $3.5 billion. Nationally they are $15 billion.

Overall, the costs associated with illegal immigrants is much higher for state and local governments than the federal government. States pay $89 billion, Uncle Sam, $46 billion.

The states paying the most to care for illegals:

  1. California – $23,038,125,353
  2. Texas – $10,994,614,550
  3. New York – $7,489,141,357
  4. Florida – $6,290,429,108
  5. New Jersey – $4,466,838,574
  6. Illinois – $3,220,767,517
  7. Georgia – $2,487,719,503
  8. North Carolina – $2,437,965,113
  9. Maryland – $2,378,996,947
  10. Arizona – $2,314,131,964

Focusing on Healthcare Costs of Illegal Immigrants Draws Attention Away from the Real Problem

Too many illegal immigrants are overwhelming the health care system and driving up health insurance costs. That’s the latest sound bite in the war of words over immigration reform. In a recent poll, a majority of the respondents thought that illegal immigrants were responsible for 50 percent or more of the uninsured treated in Southern California hospitals. But is that really the case?

While it is true that providing treatment to undocumented immigrants creates a drain on hospital resources, the question is: How much of the problem can reasonably be attributed to the undocumented? And if we solved the problem of illegal immigration tomorrow — which we won’t — would health care costs return to “reasonable” levels?

Illegal immigrants are responsible for roughly 20 percent of the $2 billion in unreimbursed care that Southern California hospitals deliver each year. Even if you consider that factor, you have to conclude that it’s the larger problem of just simply having so many uninsured patients that is a key driver of rising hospital costs.

In order to receive federal Medicare and Medicaid payments, a hospital must agree to treat and stabilize everybody who shows up to a hospital ER regardless of their ability to pay or their immigration status. That means undocumented immigrants who show up at the emergency room will receive treatment regardless of their immigration status or whether they’re insured. But so will legal immigrants, naturalized citizens and native-born Americans.

It is a matter of law that these people receive treatment. Indeed, we may have an ethical responsibility to do so as well. The problem is that most hospitals in California end up being paid for only about 5 percent of the medical care given to uninsured patients. And that leads to the question: So, who’s going to pick up the tab?

In the absence of strong political leadership on the question of insuring the uninsured, the answer, inevitably, is that hospitals and those patients with insurance, as well as those uninsured who do pay, will end up paying for those who seek care without insurance — regardless of whether they are here legally or not.

An ironic healthcare twist for undocumented immigrants

The University of Michigan Medical School study noted that the undocumented immigrants are in the country illegally. Or maybe they had protected status before but lost it due to policy changes by the current presidential administration.

Or they’re waiting for word from Congress or the courts on whether they’ll get to stay.

Whatever their situation under the law, the 11.3 million undocumented immigrants currently in the United States still need, and sometimes get, health care.

Even if they don’t have health insurance, federal law requires hospitals to care for them in emergencies. They can turn to safety-net clinics for basic needs.

Now, a new analysis highlights an ironic development in the intertwined issues of immigration and health care – two areas where the current and previous administrations differ greatly.

Undocumented people in certain states may get more medical help while they are here, it finds, thanks to the current administration’s effort to give states more flexibility with their health care spending. And in a reversal of the previous administration’s stance, states may find it easier to get that permission.

In a new article in the New England Journal of Medicine, two members of the University of Michigan Institute for Healthcare Policy and Innovation unpack recent events, political philosophies and medical evidence about caring for the undocumented.

They conclude that more states may want to apply for permission to use state and federal dollars to pay safety-net hospitals that care for everyone – whether or not they are here legally.

Waivers already in action

Such permission, which requires the government to approve an application called a waiver, has already gone into effect in Florida and Texas.

As two of the states with the highest numbers of undocumented immigrants living in their borders, they’ve seen the amount of money they can award to safety-net hospitals rise by 50 percent to 70 percent.

“Ironically, the same administration that is targeting undocumented immigrants with one set of policies may be helping them get care by preserving hospitals’ abilities to serve them with other policies,” says A. Taylor Kelley, M.D., M.P.H., who led the analysis.

Kelley says their example may bode well for other states that, like Florida and Texas, didn’t choose to expand Medicaid under the ACA.

“The United States has one of the highest rates of uninsured people in the world among developed countries, and the Affordable Care Act was designed to increase health insurance options for men, women, and children across the country. But undocumented immigrants were excluded,” so they can’t enroll in Medicare or Medicaid, or buy a plan on the ACA marketplace, explains Kelley, who is a clinical lecturer in general internal medicine at the U-M Medical School and a National Clinician Scholar at IHPI.

“Undocumented immigrants rely on safety-net institutions that deliver care for people, with insurance or without insurance,” he explains. “Safety net hospitals are also major employers and economic drivers in their communities. And so to keep their doors open, states can seek federal permission to increase the funding they get. And generally, the current administration has been very receptive.”

States didn’t get a warm welcome from the Obama administration for such waivers, because that administration’s priority was encouraging states to expand Medicaid coverage to all low-income adults – or at least those who had legal status. In fact, the previous administration said it would take away existing funding for safety-net hospitals in states that didn’t expand Medicaid.

Florida actually decided to redirect some of its own funds to help its hospitals, rather than expand Medicaid, when its waiver was ended by the Obama administration.

A door closes, a door opens 

But with the change in administrations, Kelley and co-author Renuka Tipirneni, M.D., M.Sc., write, the states that didn’t expand Medicaid and have high numbers of undocumented residents may find it easier.

States along the Mexican border, for instance, may want to seek a waiver – or apply to take part in a program that incentivizes new care delivery models for poor patients.

As for the states that did expand Medicaid, only time will tell if the government will also approve waivers to further ease the financial burden on safety net hospitals and clinics there.

A recent IHPI report about Michigan’s Medicaid expansion finds that while hospitals saw their uncompensated care drop by an average of 50 percent in the first year after expansion, the level has stayed flat since that time.

So hospitals are still absorbing the cost of caring for many people who can’t pay their medical bills, whether it’s because they have no insurance or they can’t afford the part of their bill that their insurance expects them to pay. Around half of the undocumented immigrants in the U.S. lack insurance of any kind, according to estimates.

“The major question when talking about state flexibility is, where are the limits? And how much are we going to honor states’ rights?” says Kelley. “Both Medicaid expansion and support for the safety net are programs where states are now being given the autonomy to act as they feel best for the people within their borders. Will these approaches be honored by the administration as a state right?”

Spending up front, or later 

At the same time, Kelley notes, the inpatient hospitals that have historically received the waiver funds are more and more likely to be part of new network-based models of care, such as accountable care organizations, which makes it easier for them to offer integrated care for those who come through the doors of their emergency rooms.

That may mean it’s easier to care for undocumented immigrants in a preventive or early-stage way, rather than waiting for an emergency.

In addition, Congress recently extended funding for federally qualified health centers that provide care to underserved patients outside of the hospital.

Such care can actually save money, according to research cited in the new piece. For instance, one study showed that states can save money by covering dialysis care for undocumented immigrants whose kidneys are failing, rather than waiting to provide the legally required emergency dialysis when they are in crisis. Illinois has even gone so far as to cover kidney transplants for undocumented people, because of the potential long-term cost savings.

Other research shows that expansion of individual insurance coverage provides better outcomes and use of resources than insurance for some and no insurance for others who must turn to safety net care, says Kelley. But the political philosophies and policy stances of current leadership don’t make expanded coverage likely right now.

“We’ve come out of eight years of one way of thinking, now we’re in a new way of thinking,” says Kelley. “And it’s a new shift for states if they’re going to cover the people they need to cover and help institutions out, then they have to shift their focus and their thinking.”

“Some might ask, what does care for the undocumented have to do with me as an American citizen. And the reality is that, because we provide care to anyone who stands in need of a health emergency, we all pay for everyone’s healthcare sooner or later,” he says. “When we provide access to care for undocumented immigrants, it’s not necessarily going to be a cost burden every time. In some ways, it may be beneficial to us in both indirect ways and even in direct ways.”

The impact of undocumented workers on health care costs

The Pew Charitable Trusts recently outlined the quietly building demand that undocumented workers will place on the health care system as they age.

Dan Cook of Benefitspro.Com reviewed a 2014 report which found that undocumented immigrants who needed kidney dialysis cost Texas taxpayers $10 million—much of which could have been avoided, had the immigrants been able to treat their disorders upstream. Talk about a one-two punch to the U.S. healthcare system’s gut. First, there are the widely publicized 40 million new clients that will enter Medicare’s ranks by 2050 as Baby Boomers age into the system. Then, there’s the much less publicized, but still ominous, aging undocumented worker wave about to hit the system.

This group, representing millions of illegal immigrants, is for the most part uninsured. To date, its members have made few demands on a system they don’t trust and can’t afford. But as they age and their health breaks down, they will find the system, and in all likelihood, enter through its most expensive doors: the ER or hospital admissions. Unable to pay for the care they receive, their cost will be shifted to the same health systems and insurers already panicking about how to care for those with coverage.

The Pew Charitable Trusts outlined this quietly building demand in its Stateline publication. An article entitled Aging, Undocumented and Uninsured Immigrants Challenge Cities and States reviewed research on the healthcare needs these estimated 11 million undocumented residents will have as they grow older in America. Because most don’t even qualify for Medicaid, they will be forced to go to hospitals and emergency rooms for treatment as conditions that have gone untreated worsen with age. And, the article concluded, the current health care model in the U.S. makes no provision for covering the cost of their care beyond shifting it to those with coverage.

“… Senior citizens without documentation don’t have access to care for chronic issues such as kidney disease and high blood pressure. What’s more, experts predict that many will forgo primary preventive care even when it is available, likely making their chronic health problems worse — and more expensive to treat,” the article said.

Author Teresa Wiltz noted that there are pockets across the U.S. where local communities have addressed this coming crisis with local dollars. Washington, D.C., Los Angeles and San Francisco have developed funding streams for programs that make regular health check-ups and treatment available and affordable to immigrants regardless of their status.

But throughout most of the U.S., the health of undocumented workers remains invisible. That is until somebody puts a number on it.

The Pew article cites statistics from Texas, an especially difficult state for undocumented workers to receive regular or preventive health care. There, a 2014 report found, undocumented immigrants who needed kidney dialysis and couldn’t pay for it cost state taxpayers $10 million—much of which could have been avoided had the immigrants been able to treat their disorders upstream.

What’s the solution? Conservatives tend to default to the “go back to from where you came” strategy. “The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem,” Steven Camarota, director of research for the Center for Immigration Studies, a conservative think tank that favors limiting immigration, told Stateline.

For others of a more liberal bent, the answers aren’t so off-the-shelf. Community health centers could be expanded and encourage more illegal immigrants to get regular care. Federal policies could be loosened to open up Medicaid or other options. Becoming a citizen should be made easier, especially for seniors, say others.

Meantime, hospitals and insurers play the cost-shifting game and hope for help from the nation’s capital—where the political wrangling over individual health care access seems unaffected by the looming crisis brought on by aging Americans.

The Affect on Texas

Rohit Kuruvilla and Rajeev Raghaven, doctors at Baylor College of Medicine researched the impact on Texas and found the providing health care to the 1.6 million undocumented immigrants in Texas is an existing challenge. Despite the continued growth of this vulnerable population, legislation between 1986 and 2013 has made it more difficult for states to provide adequate and cost-effective care. As this population ages and develops chronic illnesses, Texas physicians, health care administrators, and legislators will be facing a major challenge. The new legislation, such as the Affordable Care Act and immigration reform, does not address or attempt to solve the issue of providing health care to this population. One example of the inadequate care and poor resource allocation is the experience of undocumented immigrants with end-stage renal disease (ESRD). In Texas, these immigrants depend on safety net hospital systems for dialysis treatments. Often, treatments are provided only when their conditions become an emergency, typically at a higher cost, with worse outcomes. This article reviews the legislation regarding health care for undocumented immigrants, particularly those with chronic illnesses such as ESRD, and details specific challenges facing Texas physicians in the future.

Introduction- The undocumented immigrant population in Texas has been increasing since 2008 with a current estimate approaching 1.6 million persons.1 Although this may be attributed primarily to proximity to the US-Mexico border, the favorable growth of the Texas economy and the creation of low-wage jobs predicts a continued increase along this path over the next decade.  Addressing the health care needs of undocumented immigrants and their families constitutes an existing problem that is solved currently by a patchwork of clinics, safety net hospital systems, and uncompensated charity care. We expect this problem to increase as this population ages and develops costly chronic illnesses such as obesity, diabetes, heart disease, kidney disease, and cancer. Unfortunately, forthcoming national health care and immigration reform legislation do not adequately address the issue of health care for this population.

Undocumented immigrants with end-stage renal disease (ESRD) represent a patient population at the center of this problem. These patients require dialysis treatments several times a week for survival. The lack of a uniform national policy to cover the cost of dialysis for noncitizens forces local health care systems into the ethical dilemma and financial challenge of providing adequate, cost-effective care for these patients. Not surprisingly, the type and frequency of dialysis treatments that an undocumented immigrant receives vary between El Paso and Houston, and even within a particular city, such as Houston.

This article reviews the past, present, and future legislation regarding health care for undocumented immigrants while describing the challenge of managing these patients with a chronic illness, such as ESRD.

Delivering Health Care to Undocumented Immigrants- The Pew Research Center estimates that 11.2 million undocumented immigrants reside in the United States. Approximately 14% of these persons live in Texas, and this number is expected to increase.1 Primary care is delivered to this population at 1 of the 69 federally qualified health centers (FQHCs) in Texas or via safety net hospital systems. Both locations care for uninsured and indigent patients, regardless of citizenship. The FQHCs receive money from the federal government and are equipped to provide both primary and preventative care. Safety net hospital systems (also called “county” or “public” hospitals) tend to be located in larger cities (e.g., Houston or San Antonio) and are funded by their specific county. Although they offer a multitude of services, including specialist care and elective surgeries, a longer wait time is usually involved. One unfortunate consequence of the current system is that patients often present to the emergency room with a more advanced disease due to lack of early diagnosis or treatment. The resulting health care costs more and is often either uncompensated or inadequately compensated.

Besides the relative lack of access to specialists, undocumented immigrants face cultural and social barriers in obtaining care. One major cultural barrier is language; more than 75% of undocumented immigrants come from Spanish-speaking countries, and most are not fluent in English. Two social barriers often encountered are difficulty keeping medical appointments because of an irregular work schedule and fear of deportation or exposure to the law.

Legislation- Between 1986 and 2013, many legislative documents have addressed the issues of health care and immigration. The various tables summarize the four most comprehensive acts, which are detailed below.

1986: Emergency Medical Treatment and Labor Act (EMTALA)- Signed in 1986, EMTALA stipulates that any person, regardless of his or her legal status, insurance status, or ability to pay, who presents to an emergency room must be medically stabilized before discharge or transfer. This law was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer. According to the law, an emergency medical condition is defined as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the person’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”

1996: Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) – The “Permanent Residents Under Color of Law” (PRUCOL) status applies to persons whom the United States acknowledges are here illegally but for whom the country is not actively pursuing deportation. Under this status, these undocumented immigrants were granted access to many public benefits. However, in 1996, PRWORA eliminated classifying undocumented immigrants as PRUCOL status, effectively terminating their access to certain benefits (eg, welfare programs and Medicaid). Some states appealed this and continue to grant PRUCOL status to undocumented immigrants.  In California and Massachusetts, the PRUCOL status given to the undocumented immigrants allows them to receive certain health care benefits, such as scheduled dialysis. However, in Texas, undocumented immigrants are not given PRUCOL status and, hence, do not receive any public or health care benefits.

2013: Border Security, Economic Opportunity, and Immigration Modernization Act of 2013 (S 744)- Passed by the Senate in June 2013 by a vote of 68-32, this bill was awaiting approval by the House of Representatives as of May 2014. Its three primary goals are the following: to enhance border security, to renovate the immigration system by integrating the current undocumented immigrant population, and to streamline the citizenship process for highly skilled and educated persons.1 Ultimately, this bill will reduce the number of undocumented immigrants as a result of strengthened border security (adding 40,000 new agents to border patrol) and enforced hiring codes, while encouraging persons with broader educational achievement and economic potential to come into the United States through an extended visa program.

Undocumented immigrants who have lived in the United States since 2011 will be addressed as registered provisional immigrants (RPIs). After paying an initial $500 fee and any back taxes a person may owe, these immigrants may receive the RPI status if they have no criminal history. The RPI status must be extended after a 6-year probationary period. After 10 years, an RPI can apply for permanent residence, and at 13 years for citizenship. While the 13-year path to citizenship is an extended process, it affords current undocumented residents legal rights and provides them with a stable environment, relieving fears of deportation.

This act does not address health care for persons of RPI status. Hence, if this bill is signed into law, the challenge of providing care to undocumented immigrants will continue and may even increase as these persons will “come out of the shadows” and be more likely to seek primary, preventative health care and, eventually, specialist care.

2014: Patient Protection and Affordable Care Act- The Patient Protection and Affordable Care Act (ACA), also named Obamacare, has been under intense scrutiny and debate since its inception. Regarding health care for undocumented immigrants, RPIs, and persons on a visa, much debate has produced no conclusive answers. Obamacare was passed in 2010; it envisions complete national coverage by 2019 via a series of mandates, subsidies, and insurance exchanges. The act requires all legal residents to purchase insurance and penalizes those who do not. While Section 246 of the bill claims that “there shall be no federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States,” argument has ensued on where this places RPIs and how this will affect undocumented immigrants.

Until they receive full citizenship, neither undocumented immigrants nor RPIs will gain access to health care under the ACA as it is written today. They will be exempt from the mandatory fee imposed on uninsured citizens, and they will be unable to purchase health care insurance.

Texas and the Medicaid Expansion- The ACA can be expected to have several direct and indirect effects in Texas. Although Texas has declined Medicaid expansion, ramifications from the bill will still be present as federal insurance subsidies and the insurance trading market will be available to Texas residents. The ACA also calls for decreased reimbursements to disproportionate share hospitals (DSHs) under the assumption that most persons will be insured. In theory, this would reduce money available to care for undocumented immigrants and possibly place DSH (safety net hospitals) at jeopardy for hospital shutdown or withdrawal of certain services. Texas, with its large undocumented immigrant population and nonrecognition of PRUCOL status, is likely to feel these changes more than other states.

Undocumented Immigrants and Emergent Dialysis- All patients with ESRD require dialysis treatments to cleanse the blood of toxins and remove excess salt and water. Dialysis is either done every day by the patient at home (peritoneal dialysis) or in a center 3 times a week (hemodialysis). All dialysis patients, particularly those who are younger and healthier, are encouraged to be listed for a kidney transplant. In 1973, Congress enacted a historic legislation guaranteeing federal or state funding for all US citizens diagnosed with ESRD to defray the high cost of this treatment. The cost of hemodialysis today is estimated at $87,000 per person annually.

Undocumented immigrants with ESRD represent a population at the crux of immigration reform, health care reform, and the rising cost of chronic illnesses. EMTALA specified that an undocumented immigrant with ESRD who is medically unstable and presents to a hospital emergency room in need of emergent dialysis must be stabilized. Interpretation of EMTALA has led many hospitals, including safety net hospitals, to practice “emergent dialysis.” In emergent dialysis, the patient is first evaluated in the emergency room and then only receives treatment if a life-threatening indication is present. Typical indications include shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia). This is in contrast to scheduled dialysis, which happens regularly.

Emergent dialysis is 3.7 times more expensive per patient due to the associated costs of emergency room care (laboratory draws, studies, and physician fees) and more frequent patient hospitalizations as a result of poor health.9 Despite this high cost, this practice has been the standard of care because of the perceived notion that offering scheduled dialysis to undocumented immigrants could trigger an influx of immigrants with ESRD to the state. In the past decade, individual counties or cities have devised unique solutions to this problem.  For example, all patients in San Antonio receive scheduled dialysis, paid for by the county hospital system via contract to local for-profit dialysis centers; in Dallas, patients only receive emergent dialysis. In Houston, all patients begin with emergent dialysis, but one county-funded and county-operated dialysis center accepts emergent dialysis patients when space becomes available. The figures show this variability in care across these three cities in Texas. This same variability in dialysis options exists across the United States for this population.

More than 400,000 US citizens receive dialysis. Through extrapolation of published incident rates, experts estimate that 6000 undocumented immigrants in the United States require dialysis.10 From personal communication, we estimate that more than 1000 undocumented residents in Texas require dialysis. Given the high cost of dialysis and the even higher cost of emergent dialysis, Texas taxpayers are likely paying more than $10 million to manage these patients.

Emergent dialysis is not just more costly but also forces physicians into making difficult ethical decisions, such as deciding “which patient should receive treatment.” It is also associated with worse patient outcomes; the patient suffers physically from infrequent dialysis and financially from lost wages secondary to an inability to work around an irregular dialysis schedule.

Conclusion-Texas has a large, growing population of undocumented immigrants. Providing comprehensive health care to this population is a challenge, and these patients rely on safety net hospital systems. Legislation from 1986 to 2013 has made it increasingly difficult for these persons with chronic illnesses to receive cost-effective, adequate care. Undocumented immigrants with ESRD receive dialysis in Texas primarily when it becomes an emergent condition. While future RPI status may grant undocumented immigrants legality, the ACA specifies that this does not grant access to health care. With a growing undocumented immigrant population in Texas, our state legislators must be aware of and address this problem before it evolves into a health care crisis.

So, we have to learn from the European experience that if we as a country decide that we are responsible for all the undocumented illegal immigrants we need to find a way to pay for the increasing expense of allowing the immigrants to enter our country illegally.

FACT CHECK: Trump’s False Claims On ‘Medicare For All’ and Yes the Senate defeats a ​measure to overturn Trump expansion of non-ObamaCare plans, but now back to Pre-Existing Conditions

19657154_1241634215966235_4531903697739664365_nI think that I mentioned that an important issue for the Mid-Term elections was going to be healthcare and last week look how health care was treated. Peter Sullivan wrote that the Senate on last Wednesday defeated a Democratic measure to overrule President Trump’s expansion of non-ObamaCare insurance plans as Democrats seek to highlight health care ahead of the midterm elections.

The Democratic measure would have overruled Trump’s expansion of short-term health insurance plans, which do not have to cover people with pre-existing conditions or cover a range of health services like mental health or prescription drugs.

It was defeated on an extremely narrow, mostly party-line 50-50 vote, with Sen. Susan Collins (R-Maine) voting with Democrats in favor of overturning the short-term plans.

Republicans argue the short-term plans simply provide a cheaper option alongside more comprehensive ObamaCare plans.

Democrats forced the vote ahead of the midterms in an attempt to put health care front and center in the campaign. Democrats said Republicans voting to keep in place these “junk” insurance plans that do not have to cover pre-existing conditions was another example they can use to paint the GOP as wrong on health care.

“In a few short weeks the American people will head to the polls where they can vote for another two years of Republican attempts to gut our health-care system, or they can vote for Democratic candidates who will safeguard the protections now in place and work to make health care more affordable,” Senate Democratic Leader Charles Schumer (N.Y.) said on the Senate floor Wednesday.

Sen. Lamar Alexander (R-Tenn.), the chairman of the Senate Health Committee, forcefully pushed back, saying short-term plans provide a cheaper option than ObamaCare and if people want full ObamaCare plans with all the protections, they can still have them.

With short-term plans, Alexander said the message is “you can pay less with less coverage and at least you will have some insurance.”

“But our Democratic friends will say, ‘Oh no, we don’t want to do anything that will lower the cost of insurance,’” Alexander added.

Health-care experts say the short-term plans pose a risk of siphoning healthy people away from ObamaCare plans, leading to an increase in premiums for those remaining in the ObamaCare plans.

“The rule threatens to split and weaken the individual insurance market, which has provided millions of previously uninsured people with access to quality coverage since the health care law went into effect,” a range of patient groups, including the American Cancer Society and American Heart Association, said in a joint statement this week opposing the Trump administration’s short-term plans rule.

The rules that Democrats seek to overturn, which the Trump administration finalized in August, lifted a three-month restriction on short-term plans, allowing them to last up to a year. Critics say this makes the plans not really “short-term” at all.

“Our constituents deserve more options, not fewer,” Senate Majority Leader Mitch McConnell (R-Ky.) said Wednesday. “The last thing we should do is destroy one of the options that are still actually working for American families.”

Scott Horsley mentioned that USA Today published an opinion column by President Trump Wednesday in which the president falsely accused Democrats of trying to “eviscerate” Medicare while defending his own record of protecting health care coverage for seniors and others.

The column — published just weeks ahead of the midterm elections — underscores the political power of health care to energize voters. But it makes a number of unsubstantiated claims.

Here are 5 points to know

1. The political context: Healthcare has emerged as a dominant issue on the campaign trail in the run-up to the November elections. According to the Wesleyan Media Project, which tracks congressional advertising, health care was the focus of 41 percent of all campaign ads in September, outpacing taxes (20 percent), jobs (13 percent) and immigration (9 percent). Democrats are particularly focused on health care, devoting 50 percent of their ads to the issue, but health care is also a leading issue in Republican commercials (28 percent), second only to taxes (32 percent).

Perhaps sensing that Democrats are gaining traction, Trump has decided to go on the attack, targeting the Democratic proposal known as “Medicare for All.”

2. Cost of the plan: Trump claims that expanding the federal government’s Medicare program would cost$32.6 trillion over a decade. But as Business Insider reports, that would actually be a discount compared with the nation’s current health care bill.

Trump’s figure was calculated by the libertarian Mercatus Center, but he fails to note that total health care spending under Medicare for All would be about $2 trillion less over the decade than currently projected. The federal government would pay more, but Americans, on the whole, would pay less.

Remember that the U.S. already spends far more per person on health care than does any other country. And when you count the tax break for employer-provided insurance, the federal government already pays about two-thirds of this bill. But because of the fragmented private insurance system, the government gets none of the efficiency or buying power that a single-payer system would provide.

3. Health care rationing: Trump claims — with no supporting evidence — that “the Democratic plan would inevitably lead to the massive rationing of health care Doctors and hospitals would be put out of business. Seniors would lose access to their favorite doctors. There would be long wait lines for appointments and procedures. Previously covered care would effectively be denied.”

The detailed implementation of any single-payer plan would, of course, be subject to substantial negotiation. But the Medicare for All bill drafted by Sen. Bernie Sanders, I-Vt., states explicitly that “Nothing in this Act shall prohibit an institutional or individual provider from entering into a private contract with an enrolled individual for any item or service” outside the plan.

4. Pre-existing conditions: Trump notes that as a candidate, he “promised that we would protect coverage for patients with pre-existing conditions.” In fact, Trump and his fellow Republicans tried — unsuccessfully — to repeal the Affordable Care Act, which guarantees insurance coverage for people with pre-existing conditions. GOP plans would leave it up to the states to craft alternative protections. In addition, Republican attorneys general have sued to overturn Obamacare’s protections, and the Trump administration has declined to defend them.

America’s Health Insurance Plans, the trade group for the insurance industry, warns that ending the Obamacare guarantee could result in hardship for the estimated 130 million Americans under 65 with pre-existing conditions.

“Removing those provisions will result in renewed uncertainty in the individual market, create a patchwork of requirements in the states, cause rates to go even higher for older Americans and sicker patients, and make it challenging to introduce products and rates for 2019,” AHIP said in a statement in June.

5. The strength of Medicare: Trump wrote that “Democrats have already harmed seniors by slashing Medicare by more than $800 billion over 10 years to pay for Obamacare. Likewise, Democrats would gut Medicare with their planned government takeover of American health care.”

He is repeating a claim that was widely debunked during the 2012 election. The Affordable Care Act actually strengthened the solvency of Medicare, but it has since been weakened again by the GOP tax cut.

The president is trying to play on the fears of seniors — who vote in large numbers — with the claim that any effort to improve health security for younger Americans must come at their expense. But that is a false choice.

Donald Trump: Democrats ‘Medicare for All’ plan will demolish promises to seniors

Our dear President recently stated “the Democrats want to outlaw private health care plans, taking away freedom to choose plans while letting anyone cross our border. We must win this.”

Throughout the year, we have seen Democrats across the country uniting around a new legislative proposal that would end Medicare as we know it and take away benefits that seniors have paid for their entire lives.

Dishonestly called “Medicare for All,” the Democratic proposal would establish a government-run, single-payer health care system that eliminates all private and employer-based health care plans and would cost an astonishing $32.6 trillion during its first 10 years.

As a candidate, I promised that we would protect coverage for patients with pre-existing conditions and create new health care insurance options that would lower premiums. I have kept that promise, and we are now seeing health insurance premiums coming down.

I also made a solemn promise to our great seniors to protect Medicare. That is why I am fighting so hard against the Democrats’ plan that would eviscerateMedicare. Democrats have already harmed seniors by slashing Medicare by more than $800 billion over 10 years to pay for Obamacare. Likewise, Democrats would gut Medicare with their planned government takeover of American health care.

The Democrats’ plan threatens America’s seniors

The Democrats’ plan means that after a life of hard work and sacrifice, seniors would no longer be able to depend on the benefits they were promised. By eliminating Medicare as a program for seniors, and outlawing the ability of Americans to enroll in private and employer-based plans, the Democratic plan would inevitably lead to the massive rationing of health care. Doctors and hospitals would be put out of business. Seniors would lose access to their favorite doctors. There would be long wait lines for appointments and procedures. Previously covered care would effectively be denied.

In practice, the Democratic Party’s so-called Medicare for All would really be Medicare for None. Under the Democrats’ plan, today’s Medicare would be forced to die.

The Democrats’ plan also would mean the end of choice for seniors over their own health care decisions. Instead, Democrats would give total power and control over seniors’ health care decisions to the bureaucrats in Washington, D.C.

The first thing the Democratic plan will do to end choice for seniors is to eliminate Medicare Advantage plans for about 20 million seniors as well as eliminate other private health plans that seniors currently use to supplement their Medicare coverage.

Next, the Democrats would eliminate every American’s private and employer-based health plan. It is right there in their proposed legislation: Democrats outlaw private health plans that offer the same benefits as the government plan.

Americans might think that such an extreme, anti-senior, anti-choice and anti-consumer proposal for government-run health care would find little support among Democrats in Congress.

Unfortunately, they would be wrong: 123 Democrats in the House of Representatives — 64 percent of House Democrats —, as well as 15 Democrats in the Senate, have already formally co-sponsored this legislation. Democratic nominees for governor in Florida, California, and Maryland are all campaigning in support of it, as are many Democratic congressional candidates.

Democrats want open-borders socialism

The truth is that the centrist Democratic Party is dead. The new Democrats are radical socialists who want to model America’s economy after Venezuela.

If Democrats win control of Congress this November, we will come dangerously close to socialism in America. Government-run health care is just the beginning. Democrats are also pushing massive government control of education, private-sector businesses and other major sectors of the U.S. economy.

Every single citizen will be harmed by such a radical shift in American culture and life. Virtually everywhere it has been tried, socialism has brought suffering, misery, and decay.

Indeed, the Democrats’ commitment to government-run health care is all the more menacing to our seniors and our economy when paired with some Democrats’ absolute commitment to ending enforcement of our immigration laws by abolishing Immigration and Customs Enforcement. That means millions more would cross our borders illegally and take advantage of health care paid for by American taxpayers.

Today’s Democratic Party is for open-borders socialism. This radical agenda would destroy American prosperity. Under its vision, costs will spiral out of control. Taxes will skyrocket. And Democrats will seek to slash budgets for seniors’ Medicare, Social Security, and defense.

Republicans believe that a Medicare program that was created for seniors and paid for by seniors their entire lives should always be protected and preserved. I am committed to resolutely defending Medicare and Social Security from the radical socialist plans of the Democrats. For the sake of our country, our prosperity, our seniors and all Americans — this is a fight we must win.

And now the Vulnerable Republicans throw ‘Hail Mary’ on pre-existing conditions

Jessie Hellman reported that just recently dozens of vulnerable House Republicans have recently signed on to bills or resolutions in support of pre-existing conditions protections, part of an eleventh-hour attempt to demonstrate their affinity for one of ObamaCare’s most popular provisions.

Thirty-two of the 49 GOP incumbents in races deemed competitive by the nonpartisan Cook Political Report have backed congressional measures on pre-existing conditions in the past six weeks, according to an analysis by The Hill.

The moves, coming in the final weeks of the midterm campaign cycle, mark a course reversal for members of a party that for years railed against ObamaCare, also known as the Affordable Care Act (ACA), and called for its repeal.

Now, facing the threat of a “blue wave” and an onslaught of health-care attacks from Democratic candidates, vulnerable Republicans are running ads on pre-existing conditions and co-sponsoring measures that critics deride as meaningless.

The congressional resolutions are “a quick Hail Mary for a list of endangered incumbents,” said Thomas Miller, a resident fellow at the right-leaning American Enterprise Institute, and co-author of “Why ObamaCare is Wrong for America.”

“They’re intended to provide at least some legislative cover in the event that they can read the polls and know there’s been a stampede of support for the broad-brushed pre-existing conditions protections similar to those in the ACA,” he said.

A Kaiser Family Foundation poll in August found that more than 72 percent of Americans think the protections — prohibiting insurers from denying coverage to people with pre-existing conditions or charging them more for coverage — should remain law.

Democrats in June seized on the Trump administration’s announcement in court that it would not defend ObamaCare’s protections for people with pre-existing conditions. The Department of Justice sided in large part with the 20 Republican state attorneys general who filed a lawsuit seeking to overturn ObamaCare.

Now Democrats, who are looking to flip both the House and Senate, are tying Republicans to that decision while highlighting the GOP’s ObamaCare repeal-and-replace efforts, which they say would have diminished pre-existing conditions protections for people in the individual market.

Tyler Law, the national press secretary for the Democratic Congressional Campaign Committee (DCCC), said the “overwhelming majority” of campaign ads from the DCCC and Democrats have focused on health care, with pre-existing conditions as the central theme.

“Republicans are stuck on defense, forced to respond to devastatingly effective ads on their record on pre-existing conditions, and touting nonbinding resolutions as they panic because they see the political fallout,” Law said.

“Republicans clearly recognize how politically disastrous their policies are in regards to pre-existing conditions,” he added. “They are now just making up an alternative record on which all of a sudden they seem to care about pre-existing conditions.”

Reps. David Young (Iowa) and Pete Sessions (Texas) — two Republicans running in competitive races this year — introduced separate resolutions in September supporting pre-existing conditions protections. Later that month, Rep. Steve Knight (R-Calif.), who is locked in a toss-up race, introduced a similar bill.

Another measure — the Pre-existing Conditions Protection Act of 2017 — was introduced by Rep. Greg Walden (R-Ore.) in February of last year but has attracted 16 Republican co-sponsors in the past month and a half — all but four of whom are running in competitive races. Twenty Republicans in competitive races co-sponsored the legislation last year.

Of the 23 Republican incumbents who are considered to be most in danger of losing their seat, according to Cook Political Report, 18 co-sponsored at least one of the resolutions or bills since September.

The measures, however, are more of a political statement. They aren’t expected to pass or even get a markup at the committee level.

“It’s a political gesture,” Miller said. “You don’t introduce bills in September of 2018 with the intent of marking it up.”

Democrats say it’s part of a transparent attempt by the GOP to deflect from their failed efforts to repeal ObamaCare.

“They’re trying to claim they support protections for people with pre-existing conditions. It’s really disingenuous,” said Maura Calsyn, managing director of health policy at the Center for American Progress, a liberal think tank. “They’re hoping the public is going to ignore their past votes and their past statements that they don’t support the ACA.”

While some Republicans have pointed to their vote in favor of the GOP-backed American Health Care Act as proof they support protections for pre-existing conditions, Democrats argue that the legislation didn’t match the protections guaranteed by the ACA.

The nonpartisan Congressional Budget Office concluded last year that under the GOP bill, people with pre-existing conditions “would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law if they could purchase it at all.”

Vulnerable Republicans have also been running ads about pre-existing conditions, sometimes with a focus on their family members.

Rep. Dana Rohrabacher (R-Calif.), who is a toss-up race against Democrat Harley Rouda, recently released an ad focusing on his daughter’s pre-existing condition — leukemia.

“So for her and all our families, we must protect America’s health-care system,” Rohrabacher says in the ad. “That’s why I’m taking on both parties, and fighting for those with pre-existing conditions.”

Rohrabacher, who voted multiple times to repeal the ACA, signed on to legislation Tuesday supporting pre-existing conditions protections.

“The Republicans who are pushing now to clean things up three weeks up before the election aren’t able to do it,” said Amanda Harrington, director of communications for Protect Our Care, a pro-ObamaCare advocacy group that is involved in the midterms. “The deficit they have created themselves on the issue of health care is far too steep for them to climb.”

There are many fights going forward as we get closer to the Mid-terms and if the majorities change in the House and Senate there are going to be many more. My hope is that the children in both the House and the Senate grow up and realize that they had better learn how to work together.

On my visit to California to spend some time with my daughter, I realized how bad things still were when we discussed the last few weeks and even though Judge Kavanaugh was investigated 7 times she still believed that he was a horrible person. There was no pursuing further discussion with her or anyone else in her group of graduate students.

I was amused last week when a favorite patient of mine and a long time strategist for the Democrat party was seen in my office. As I entered the exam room she raised her right hand and flashed me a peace sign. She then apologized for the behavior of her party during the Kavanaugh hearings and that she and her husband warned them of the possible blowback.

Remember, this lady agreed with me that no matter what good pieces of legislation put to a vote before the Mid-Term elections that the Democrats would vote against, even if the legislation was what the Democrats would “normally” be in agreement at any other time. What a farce and now how do we correct this type of behavior? I’m not sure unless we vote all of those in the House and the Senate out and find some candidates who really want to improve our country despite the media who fight each day to upset our free country for a sound bite to capture the next media attention spot despite the facts.

Newt Gingrich predicted that Ignoring health care could spell disaster for Republicans in 2018 elections. Maybe, But What About the “ME-To” Wave And All Men Are Bad?

43066034_1731880880274897_8358288627561660416_nAs Newt Gingrich wrote, the U.S. economy has been growing and breaking records ever since President Trump first took office and Republicans took control of Congress.

Many in the GOP are hoping this success will help them get re-elected in November. Some consultants I’ve spoken with seem to think it will inoculate Republican candidates against most all Democratic attacks.

They are mostly right, except for one area – health care.

Here I have to modify his thoughts. I think that after this Judge Kavanaugh circus we are, no the Democrats are not finished with the “Me To”/sexual assault and “All Men Are Bad” push. They are going to mobilize the women and some of the crazy men who will listen to their leaders.

But let us continue with the health care issue.

No doubt, Republicans should be proud of the enormous success of the economy. But the economy won’t reach its full potential and the GOP will not win big in the 2018 elections unless Republicans deal with the cost of health care in America.

The reason is simple:

Health care represents nearly one-fifth of our country’s economy and is the largest driver of government spending. It is also such a huge slice of household budgets that many Americans don’t end up feeling the benefits of the 4.1 percent growth in the gross domestic product (GDP). In 2016, individual health care costs amounted to $10,328 per person (in 1960, that figure was $146).

As Dave Winston and Myra Miller at The Winston Group have noted, with nearly half of Americans saying they are living paycheck-to-paycheck (with no reserves for emergencies) it is hard for people to “feel the prosperity” implicit in a remarkably strong macroeconomy. Their individual micro-economies are too deeply impacted by the cost of health care.

Additionally, health care costs are outpacing income growth because businesses have had to eschew raises and promotions to afford more and more health care costs. According to a 2017 report by the Kaiser Family Foundation and the Health Research & Education Trust and federal income data, “premiums for an employer-provided family insurance plan have climbed 19 percent, while worker pay increased 12 percent.” The additional money Americans are receiving in their paycheck from the Tax Cut and Jobs Act helps, but lowering health care costs still needs to be a priority.

A Republican party that hides from the challenge of modernizing the health system is a party, which has conceded a huge part of the political playing field to the left.

Fortunately for Republicans – and for the country – we now have leadership capable of developing a serious strategy for a dramatically improved health care system. Secretary of Health and Human Services Alex Azar has the knowledge and the experience to help shape a new, profoundly better health system for all Americans.

Secretary Azar’s move this week to widen access to less expensive, short-duration health insurance plans was a step in the right direction. These plans will give Americans more options to buy the level of insurance they need for themselves – rather than being forced to buy more expensive coverage they don’t necessarily need.

President Trump’s earlier announced plan for reducing prescription drug prices will also be a huge help for families, and the administration’s support for the expansion of association health plans will provide more options for small businesses and self-employed individuals.

So, while there is still more work to be done, Republicans can point to positive steps that have been taken and progress that has been made — but they can’t shy away from talking about health care.

This reality of half the nation operating on the margin is what drives support for government-run health care, which is now sweeping large parts of the Democratic Party.  If Republicans refuse to articulate a better solution, a large portion of the American people will decide that government bureaucracy is better than constant economic anxiety about unknowable, increasing health costs.

As I have written before, if the left wins on health care and puts in place a single-payer system, it would be a disaster.

So, to truly win the economic argument, Republicans must think through and win the health care argument. The dynamics of the fall campaign give them no choice. The Democrats’ government-run health care system will fill the gap left by the absence of a serious Republican alternative.

There is a long tradition of Republicans trying to avoid health issues. Consultants assert “it isn’t our topic.” Incumbents find it hard to communicate a clear policy or plan for improving the health system. “Repeal and Replace” was largely about repeal because Republicans lacked a coherent plan to replace ObamaCare. This is why it failed.

A Republican party that hides from the challenge of modernizing the health system is a party which has conceded a huge part of the political playing field to the left.

Conversely, a Republican party that can explain common sense improvements that will empower Americans to have longer lives, better health, greater convenience, more choices, and lower costs in healthcare is a party that can easily demolish the left’s arguments.

Healthcare Is The No. 1 Issue For Voters; A New Poll Reveals Which Healthcare Issue Matters Most

And as Robert Pearl, M.D. stated, depending on which news outlet, politician or pundit you ask, American voters will soon participate in the most important midterm election “in many years,” “in our lifetime” or even “in our country’s history.”The stakes of the November 2018 elections are high for many reasons, but no issue is more important to voters than health care. In fact, NBC News and The Wall Street Journal found that healthcare was the No. 1 issue in a poll of potential voters.

What’s curious about that survey, however, is that the pollsters didn’t ask the next, most-logical question.

What Healthcare Issue, Specifically, Matters Most To Voters?                                          To answer this question, I surveyed readers of my monthly newsletter. Will the opioid crisis sway voters at the polls? What about abortion rights? The price of drugs? The cost of insurance?

See for yourself:

Untitled. mid-term.elections

To understand the significance of these results, look closely at the top four:

  1. Prescription drug pricing (58%)
  2. Universal/single-payer coverage (57%)
  3. Medicare funding (50%)
  4. Medicaid funding (40%)

Notice a pattern here? All of these healthcare issues come down to one thing: money.

Healthcare Affordability: The New American Anxiety                                               Because the majority of my newsletter readers operate in the field of healthcare, they’re well informed about the industry’s macroeconomics. They understand healthcare consumes 18% of the gross domestic product (GDP) and that national health care spending now exceeds $3.4 trillion annually. The readers also know that Americans aren’t getting what they pay for. The United States has the lowest life expectancy and highest childhood mortality rate among the 11 wealthiest nations, according to the Commonwealth Fund Report. But these macroeconomic issues and global metrics are not what keeps healthcare professionals or their patients up at night. Eight in 10 Americans live paycheck to paycheck. Most don’t have the savings to cover out-of-pocket expenses should they experience a serious or prolonged illness. In fact, half of U.S. adults say that one large medical bill would force them to borrow money. The reality is that a cancer diagnosis or an expensive, lifelong prescription could spell financial disaster for the majority of Americans. Today, 62% of bankruptcy filings are due to medical bills.

To understand how we’ve arrived at this healthcare affordability crisis, we need to examine the evolution of health care financing and accountability over the past decade.

The Recent History Of Healthcare’s Money Problems

Until the 21st century, the only Americans who worried about whether they could afford medical care were classified as poor or uninsured. Today, the middle class and insured are worried, too. How we got here is a story of evolving policies, poor financial planning and, ultimately, buck-passing.

A big part of the problem was the rate of health care cost inflation, which has averaged nearly twice the annual rate of GDP growth. But there are other contributing factors, as well.

Take the evolution of Medicare, for example, the federal insurance program for seniors. For most of the program’s history, the government reimbursed doctors and hospitals at (approximately) the same rate as commercial insurers. That started to change after a series of federal budget cuts and sequestration reduced provider payments. Today, Medicare reimburses only 90% of the costs its enrollees incur and commercial insurers are forced to make up the difference. As a result, businesses see their premiums rise each year, not only to offset the growth in their employee’s medical expenses but also to compensate hospitals and physicians for the unreimbursed portion of the cost of caring for Medicare patients.

Combine two high-cost factors: general health care inflation and price constraints imposed by Medicare and what you get are insurance premiums rising much faster than business revenues.

To compensate, companies are shifting much of the added expense to their employees. The most effective way to do so: Raise deductibles. By increasing the maximum deductible annually, the company reduces the magnitude of its expenses the following year, at least until that limit is reached. A decade ago, only 5% of workers were enrolled in a high-deductible health plan. That number soared to 39.4% by 2016 and jumped again to 43.2% the following year.

High-deductible coverage holds individual patients and their families responsible for a major portion of annual healthcare costs, anywhere from $1,350 to $6,650 per person or $2,700 to $13,3000 per family. This exceeds what the average available savings for most American families and helps to explain the growing financial angst in this country.

And it’s not just employees under the age of 65 who are anxious. Medicare enrollees also fear that the cost of care will drain their savings. As drug prices continue to soar, Medicare enrollees are hitting what has been labeled “the donut hole,” which means that once the cost of their “Part D” prescriptions reaches a certain threshold, patients are on the hook for a significant part of the cost. Now, more and more seniors find themselves having to pay thousands of dollars a year for essential medications.

When it comes to paying for health care, the United States is an anxious nation in search of relief. The fear of not being able to afford out-of-pocket requirements is the reason so many voters have made health care their No. 1 priority as they head to the polls this November. And it’s why both parties are scrambling to deliver the right campaign message.

On Healthcare, Each Party Is A House Divided

In the last presidential election, the Democratic Party chose a traditional candidate, Hilary Clinton, whose views on healthcare were closer to the center than her leading challenger, Bernie Sanders. Two years later, the party is divided by those who believe that (a) the only way to regain control of Congress is by fronting centrist candidates who support and want to strengthen the Affordable Care Act as the best way to attract undecided and independent voters, and (b) those who will accept nothing less than a government-run single payer system: Medicare for all. The primary election of New York congressional candidate Alexandria Ocasio-Cortez, a Sanders supporter, over long-time incumbent Joseph Crowley, represents this growing rift within the party.

The Republicans also face two competing ideologies on healthcare. Since his election in 2016, President Donald Trump has sought to dismantle the ACA. In addition, he and his political allies want to shift control of Medicaid (the insurance program for low-income Americans) from the federal government to the states—a move that would lower health care spending while eroding coverage protection. There are others in the Republican Party who worry that shrinking Medicaid or undermining the health exchanges will come back to bite them. Most of them live and campaign in states where voters support the ACA.

Do The Parties Agree On Anything?

Regardless of party, everyone, from the president to the most fervent single-payer advocate, understands that voters are angry about the cost of their medications and the associated out-of-pocket expenses. And, not surprisingly, each party blames the other for our current situation. Last week, the president gave the Medicare program greater ability to reign in costs for medications administered in a physician’s office. In addition, Trump has promised a major announcement this week to achieve other reductions in drug costs. Of course, generous campaign contributions may dim the enthusiasm either party has for change once the voting is over.

Playing “What If” With Healthcare’s Future

If both chambers remain Republican controlled, we can expect further erosion of the ACA with more exceptions to coverage mandates and progressively less enforcement of its provisions. For Republicans, a loss of either the Senate (a long-shot) or the House (more likely), would slow this process.

But regardless of what happens in the midterms, no one should expect Congress to solve healthcare’s cost challenge soon. Instead, patient anxiety will continue to escalate for three reasons.

First, none of the espoused legislative options will do much to address the inefficiencies in the current delivery system. Therefore, prices will continue to rise and businesses will have little choice but to shift more of the cost on to their workers. Second, the Fed will persist in limiting Medicare reimbursement to doctors and hospitals, further aggravating the economic problems of American businesses. whose premium rates will rise faster than overall health care inflation. Finally, compromise will prove even more elusive since so many leading candidates represent the extremes of the political spectrum.

Politics, the economy, and health care will all be deeply entangled this November and for years to come. I believe the safest path, relative to improving the nation’s health, is toward the center. Amending the more problematic parts of the ACA is better than either of the two extreme positions. If our nation progressively undermines the current coverage provisions, millions of Americans will see their access to care erode. And on the other end, a Medicare-for-all health care system will produce large increases in utilization and cost.

It’s anyone’s guess what will happen in three months. But, whatever the outcome, I can guarantee that two years from now healthcare will remain top-of-mind for voters.

The Memo: GOP to win Kavanaugh fight but Dems vow midterm revenge

Niall Stanage noted that Brett Kavanaugh is set to be confirmed to the Supreme Court on Saturday, notching a big victory for President Trump and the Republican Party — but one that carries sizable complications.

Democrats believe their voters are now more fired up than ever to deliver a rebuke to the GOP in the November midterm elections.

They vow that women’s anger at the judge’s near-certain confirmation, despite allegations of sexual assault and misconduct against him, will be a potent electoral force.

“What I have seen is anger and outrage from women in a way that I’ve never seen before,” said Karine Jean-Pierre, senior adviser and national spokeswoman for MoveOn, a progressive group. “I don’t think Republicans realize what they have unleashed.”

One national women’s group, UltraViolet Action, issued a stark two-sentence statement Friday from co-founder Shaunna Thomas.

“This doesn’t end tomorrow. It ends in November,” Thomas said.

Sen. Kamala Harris(D-Calif.), widely predicted to become a 2020 presidential candidate, made a broader argument that the GOP had disrespected women by backing Kavanaugh.

“To all survivors of sexual assault: We hear you. We see you. We will give you dignity. Don’t let this process bully you into silence,” Harris tweeted as the Kavanaugh drama neared its peak on Friday afternoon in the Senate.

Some Republicans had expressed concern earlier this week when Trump mocked Kavanaugh’s most prominent accuser, Christine Blasey Ford, during a rally in Mississippi. They worried that the president’s rhetoric seemed likely to cause deeper erosion of support for the GOP among suburban women in particular — a demographic that is already skeptical of the president.

An NPR/PBS/Marist poll conducted in late September showed Trump’s job approval rating to be very negative among college-educated white women. Fifty-seven percent within that group disapproved of Trump’s job performance, whereas only 38 percent approved.

At that time, GOP strategist Liz Mair told The Hill: “The party is already in trouble with suburban women. I just have a sneaking suspicion that the Republicans will find a way to mess this up. We are already in trouble with a group of voters we need to not totally hate us.”

But by Friday such concerns seemed to have been supplanted by satisfaction about getting Kavanaugh to the finish line.

Republicans believe they will be rewarded by conservative voters who might not have gone to the polls had GOP senators proved unable to confirm Kavanaugh, who’s spent the past 12 years as a judge on the U.S. Court of Appeals for the District of Columbia Circuit. Many social conservatives voted for Trump with a degree of ambivalence in 2016, given his colorful personal life, but did so in the hope that he would tilt the Supreme Court in their favor.

Kavanaugh’s confirmation would give the nine-member high court a solid 5-4 conservative majority.

“At the moment it appears that Republican voters, Trump voters, have re-engaged and are heading to the polls,” said GOP pollster John McLaughlin on Friday.

Had Kavanaugh plunged to defeat, McLaughlin asserted, “you would have a lot of angry Trump voters who would blame the Republicans and not show up” for the Nov. 6 midterms.

The Kavanaugh drama came to a head on Friday afternoon when Sen. Susan Collins(R-Maine), who had not previously declared her position, announced she would support him.

Moments after her announcement, Sen. Joe Manchin (D-W.Va.) became the only Democrat to cross party lines to back the judge. Manchin is seeking re-election this year in a state that Trump carried by 42 points in 2016 over Hillary Clinton.

The liberal dismay about those decisions was immediately evident on social media and elsewhere.

Susan Rice, who served as U.S. ambassador to the United Nations during former President Obama’s administration, suggested she would be willing to challenge Collins when she comes up for reelection in 2020. It was not clear if Rice was being serious.

Democracy for America, a progressive group, announced that it would work with “anyone we can to finish the job” of defeating Collins.

In a parallel development, former Alaska Gov. Sarah Palin (R) suggested she would consider challenging Sen. Lisa Murkowski(R-Alaska), who voted against Kavanaugh in a procedural vote Friday morning.

“Hey, @LisaMurkowski – I can see 2022 from my house…” Palin tweeted, referring to the year when Murkowski is up for reelection.

Beyond that, the sheer bitterness of the battle over Kavanaugh is striking to all sides.

“The starting gun for the 2020 election was fired with this confirmation fight,” said Ron Bonjean, a Republican who served as a communications strategist in the battle to confirm Trump’s first Supreme Court nominee, Neil Gorsuch, in 2017.

“This rollercoaster nomination has bonded both parties together in a way,” Bonjean added, “because of the intensity of it, how close this vote was and the unfair tactics both sides claimed the other party utilized.”

The president seemed to begin a victory lap on Friday. “Very proud of the U.S. Senate for voting ‘YES’ to advance the nomination of Judge Brett Kavanaugh!” he tweeted.

Democrats are hoping that air of celebration will be short-lived.

Who is correct? We will soon see!

 

HHS chief dismisses ‘Medicare for all’ as ‘too good to be true’ and the Black Hole that Our Politicians are Creating!

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Apologies to all those that read my posts for not posting Sunday evening. My home computer finally crashed. So, here is the weekly post for your review.

These last two weeks have convinced me that both the Republicans and Democrats are flawed and no longer deserve our support. More on that later!

But back to Medicare for All and the confirmation that it may not be the best offer for our health care system.  Nathaniel Weixel wrote that the Trump administration’s top health official on Thursday dismissed “Medicare for all” as a promise that’s too good to be true.

“When you drill down into the details, it’s clear that Medicare for all is a misnomer. What’s really being proposed is a single government system for every American that won’t resemble Medicare at all,” Health and Human Services Secretary Alex Azar said during a wide-ranging speech in Nashville, Tenn.

Azar said embracing Medicare for all would mean ignoring the mistakes of ObamaCare, which he called a failure.

“The main thrust of Medicare for all is giving you a new government plan and taking away your other choices,” Azar said.

This was not the first time a top official at the Department of Health and Human Services has tried to discredit the idea of Medicare for all. Centers for Medicare and Medicaid Services Administrator Seema Verma in July called it socialized medicine that would put seniors at risk.

Medicare for all has become increasingly popular among Democrats and is now favored by many of the party’s potential 2020 presidential candidates.

However, many congressional Democrats have yet to completely embrace the idea, and while Sen. Bernie Sanders (I-Vt.) has sponsored a “Medicare for all” bill, there’s no real push for it in Congress.

Republicans have been pointing to Democratic calls for single-payer as a key rebuttal in this year’s midterm campaign, part of an effort to push back against Democratic attacks on GOP bills to repeal ObamaCare.

Aside from attacking Medicare for all, Azar in his speech praised President Trump as a better steward of ObamaCare than former President Obama ever was.

“The president who was supposedly trying to sabotage the Affordable Care Act has proven better at managing it than the president who wrote the law,” Azar said.

He said premiums have been decreasing and there are more plans available for consumers to choose from on state exchanges.

According to Azar, premiums for the typical ObamaCare plan will decrease in 2019 by an average of 2 percent nationwide.

But insurance experts say the main reason premiums are either stable or decreasing this year is because they were so high in 2018. Insurers overpriced their plans this year, driven by the uncertainty over how the Trump administration would handle ObamaCare.

In addition, studies have shown premiums would also be decreasing much more if not for Trump administration policies like the elimination of the individual mandate penalty and expansion of short-term plan.

And now some good, positive news on the healthcare front!

Congress Passes Healthcare Appropriations Bill

Includes funding increase for NIH, $$ for opioid disorder treatment and research

  • Our friend Joyce Frieden of MedPage wrote that Congress has passed a major appropriations bill that increases funding for medical research and opioid disorder treatment and research.

The bill, which includes a $2-billion increase in the National Institutes of Health budget, passed the House Wednesday evening; the Senate passed it last Tuesday. The $674 billion measure, which also includes funding for the departments of Labor and Defense, now heads to the White House, where President Trump is expected to sign it before Oct. 1, in time to avoid a government shutdown.

Medical groups praised the bill’s passage. “We applaud congressional approval of the FY19 Labor-HHS/Defense spending bill which ensures increased funding for innovative research and public health initiatives to address deadly and disabling diseases,” Mary Woolley, CEO of Research!America, a trade group for medical research organizations, said in a statement. “Passage of the measure before the end of the current fiscal year is also noteworthy and congressional leaders should be commended for their commitment to advancing the bill in a timely fashion. The $2-billion increase for the National Institutes of Health builds on the momentum to accelerate research into precision medicine, Alzheimer’s disease, cancer, and other health threats.”

In addition, she noted, “The measure will also enable the Centers for Disease Control and Prevention to step up efforts to combat antibiotic resistance, and the opioid epidemic through research, treatment, and prevention.”

The appropriations bill also includes $317 million for various rural health initiatives, including $20 million for the Small Rural Hospital Improvement Grant Program for quality improvement and adoption of health information technology, and up to $1 million for telehealth services, “including pilots and demonstrations on the use of electronic health records to coordinate rural veterans’ care between rural providers and the Department of Veterans Affairs electronic health record system,” according to the conference report on the bill that was worked out between the House and Senate.

Other health-related provisions of the bill include:

  • $1.5 billion for State Opioid Response Grants
  • $765 million to the Centers for Medicare & Medicaid Services for fighting fraud
  • $338 million for the Agency for Healthcare Research and Quality, which had been targeted for closure by the Trump administration
  • $120 million for the Rural Communities Opioids Response Program

The Association of American Medical Colleges (AAMC) also applauded the bill’s passage. In addition to the NIH funding bump, “funding for the Health Resources and Services Administration’s workforce and pipeline programs will help create a strong and culturally competent health care workforce to provide those cures and treatments to vulnerable patients and those living in underserved communities,” AAMC president and CEO Darrell Kirch, MD, said in a statement.

In her statement about the bill’s passage, Rep. Lucille Roybal-Allard (D-Calif.) singled out the healthcare provisions in particular. “I am particularly pleased that [Health and Human Services] programs received such robust funding in this Conference agreement,” she said. “The bill increases funding for three of my top legislative priorities: fighting underage drinking, supporting newborn screening, and reducing maternal mortality.”

In addition, “at a time when this country is experiencing the highest rates of sexually transmitted diseases in history, this bill restores both the Teen Pregnancy Prevention Program and all Title X Family Planning dollars that help our teens gain critical access to reproductive health care and education.”

But not everyone was happy with the bill. “We’re pleased policymakers have likely avoided a shutdown and actually appropriated most of this year’s discretionary budget on time,” said Maya MacGuineas, president of the Committee for a Responsible Federal Budget, in a statement. “But let’s not forgot that Congress did so without a budget and had to grease the wheels with $153 billion to pass these bills. That isn’t function; it’s a fiscal free-for-all.

“Policymakers should not be budgeting by borrowing more; they should put in place a full budget with a plan to bring our borrowing down, not up,” she continued. “Let’s stop patting ourselves on the back for adding hundreds of billions of dollars to the deficit in an orderly manner. Let’s instead work together to stabilize the nation’s finances.”

 ‘Indelible in the Hippocampus’: Christine Blasey Ford Explains Science Behind Her Trauma

The teaching psychologist Dr. Ford explained the uneven memories of sexual assault survivors to the Senate Judiciary Committee.

Anna Almendria wrote that while recounting her allegations against Supreme Court nominee Brett Kavanaugh in front of the Senate Judiciary Committee Thursday, Christine Blasey Ford said the judge had covered her mouth to prevent her from screaming during an assault while the two were teenagers in high school. In follow-up questions, Sen. Dianne Feinstein (D-Calif.) asked Blasey how she could be so sure that it was Kavanaugh who did it.

Blasey, who is a psychology professor at Palo Alto University, offered a lesson in neuroscience in reply.  “The same way that I’m sure that I’m talking to you right now, just basic memory functions,” Blasey told Feinstein in response. “And also just the level of norepinephrine and epinephrine in the brain that sort of, as you know, encodes ― that neurotransmitter encodes memories into the hippocampus, and so the trauma-related experience then is kind of locked there whereas other details kind of drift.”

Norepinephrine and epinephrine are two hormones released when the body experiences stress. When a person is experiencing a threat like a sexual assault, these stress neurotransmitters flood the brain and help encode details like the environment and the people who you’re with on the hippocampus, which is a part of the brain that’s responsible for creating and retrieving memories.

Later on in the hearing, she again referred to the hippocampus when responding to Sen. Patrick Leahy’s (D-Vt.) question about her most vivid memory of the alleged assault, which Blasey said took place in the early 1980s.

“Indelible in the hippocampus is the laughter, the uproarious laughter between the two,” she said, referring to Kavanaugh and Mark Judge, the other person Blasey alleges was in the room when the assault took place. “And their having fun at my expense.”

In pairing the retelling of her traumatic experience with explanations of the way assault affects the brain, Blasey is educating the public about how survivors process and store violent memories and can recall them years later.

Sabrina Segal, a psychology professor at Cal State University, Channel Islands, says that Blasey was making a distinction between everyday memories that the brain records during calm, relaxed moments and traumatic memories that the brain encodes during periods of high stress and fear for one’s life.

“The hippocampus is a structure in the brain that we know basically converts short-term memory traces into long-term memory traces,” Segal said, a term that psychologists use to describe the physical change that takes place in the brain when it stores a memory. “We know this because of studies where this part of the brain was removed, and it altered a person’s ability to do that.”

This bit of biology explains why Blasey would be certain of some details like Kavanaugh’s face, or the environment of the room and less so of other details that occurred before the alleged assault, such as the owner of the home where the incident took place. In moments where she feared for her life and was in “fight or flight” mode, she would have details “seared” into her memory, Segal said.

The full mechanics of this response also involve the amygdala, an almond-shaped structure in the brain, which perceives and responds to danger.

“What a lot of people don’t know is that your body releases adrenaline, which is a stress hormone, and almost simultaneously your brain will release [norepinephrine] in the amygdala,” Segal said. “It’s a potency maker in terms of being able to strengthen the memory.”

Research shows that it is common for survivors of sexual trauma to strongly remember the details of the event itself but not have many memories of other details around the event.

“When something is incredibly traumatic and emotional, that [norepinephrine] is going to make specific details etched in, and you will never forget them,” Segal said. “The fact that she’s had these memories for 20 years is not shocking to me in any way.”

Negar Fani, an assistant professor at Emory University who specializes in the neurobiology of post-traumatic stress disorder, says that this traumatic memory-storing process has a strong evolutionary purpose.

“It’s so that you can avoid things that could potentially harm you in the future,” Fani said. “When you encounter and encode these contextual aspects of the memory, you’ll avoid things that even remotely relate to that trauma memory.”

Fani said this could explain why Blasey requested that Kavanaugh not be present in the room during her testimony. “This person who assaulted her produces that same fight or flight reaction,” Fani said. “Because he’s a critical part of the threat context, it’s going to arouse her fight or flight system, and it’s hard to think clearly when that fight or flight system is engaged.”

But there is a lesson for Dr. Ford, and these experts, who has accused the supreme court nominee, Judge Kavanaugh, of sexual harassment saying that the norepinephrine and epinephrine levels in her hipocampus basically cements that memory 100% in her hippocampus. Interesting!! If that were true how come that she doesn’t remember where it took place, when it took place and how she got home.

Well, the last article the “professionals” tries to explain these differences. Alas, this “expert”, along with those others, who are not medical doctors with no training in neurology or medicine don’t understand the effect of alcohol has on the levels of norepinephrine in the hippocampus or chose not to mention these facts. Study up Doc/PhD, before you try to sound so sure of yourself.

Now also remember the Prosecutor that the Republicans brought in to question Ford and Kavanaugh. Rachel Mitchell, the prosecutor who questioned Christine Blasey Ford on behalf of Republican senators last week during an emotional hearing before the Senate Judiciary Committee, released a memo late Sunday detailing why no “reasonable prosecutor” would bring a case against Brett Kavanaugh given the “evidence” that exists against him.

“A ‘he said, she said’ case is incredibly difficult to prove. But this case is even weaker than that,” Mitchell said, explaining the case’s “bottom line.”

Ironically, Mitchell’s language mirrors the vernacular of former FBI Director James Comey, who similarly argued in July 2016 that “no reasonable prosecutor” would bring charges against Hillary Clinton for her use of a private email server.

The career Arizona prosecutor, who specializes in sex-related crimes, goes on to outline eight reasons why no “reasonable prosecutor would bring this case,” explaining the evidence fails to “satisfy the preponderance-of-the-evidence standard.”

  1. Ford has not offered a consistent account of when the alleged assault happened

Mitchell explained that initially Ford said the assault occurred in the “mid-1980s,” but later changed the date to the “early 80s.” But when she met with the polygraph administrator, Ford crossed out the word “early” for unknown reasons.

Ford has also described the incident occurring in the “summer of 1982” and her “late teens” — despite claiming it happened when she was 15.

“While it is common for victims to be uncertain about dates, Dr. Ford failed to explain how she was suddenly able to narrow the time frame to a particular season and particular year,” Mitchell said.

  1. Ford has struggled to identify Judge Kavanaugh as the assailant by name

Mitchell explained Ford neither identified Kavanaugh by name during marriage counseling in 2012 or individual counseling in 2013. Ford’s husband claims she identified Kavanaugh in 2012, but Mitchell noted that Kavanaugh’s name was widely circulated as a potential Supreme Court pick should then-Republican presidential nominee Mitt Romney have won the presidency.

“In any event, it took Dr. Ford over thirty years to name her assailant,” Mitchell wrote. “Delayed disclosure of abuse is common so this is not dispositive.”

  1. When speaking with her husband, Ford changed her description of the incident to become less specific

According to Mitchell, Ford told her husband before they married that she had been the victim of a “sexual assault,” but told the Washington Post that she told her husband she was a victim of “physical abuse.”

“She testified that, both times, she was referring to the same incident,” Mitchell said.

  1. Ford has no memory of key details of the night in question — details that could help corroborate her account

Mitchell explained:

  • Ford does not remember who invited her to the “party, how she heard about it, or how she got there”
  • Ford does not remember whose house the assault occurred or where the house is located with any specificity
  • Ford remembers very specific details about that night that are unrelated to the assault, such as how many beers she consumed and whether or not she was on medication

Perhaps the most significant hole in Ford’s memory, Mitchell said, is the fact that Ford does not remember how she returned home from the party.

Factually speaking, the location of the party that Ford identified to the Washington Post is a 20-minute drive from her childhood home. And it was only during her testimony last week that she agreed for the first time that someone had driven her somewhere that night. Ford remembers locking herself in a bathroom after the alleged assault, but cannot identify who drove her home.

Significantly, no one has come forward to identify themselves as the driver.

“Given that this all took place before cellphones, arranging a ride home would not have been easy. Indeed, she stated that she ran out of the house after coming downstairs and did not state that she made a phone call from the house before she did, or that she called anyone else thereafter,” Mitchell said.

  1. Ford’s account of the alleged assault has not been corroborated by anyone she identified as having attended — including her lifelong friend

As widely reported, Mitchell explained that each individual Ford identified as having been at the party has submitted sworn statements — under penalty of felony — that they do not remember the party and cannot recall or corroborate any detail that Ford alleges.

  1. Ford has not offered a consistent account of the alleged assault

Ford claimed in her letter to Sen. Dianne Feinstein (D-Calif.) that she heard Kavanaugh and Mark Judge talking downstairs while hiding in a bathroom after the assault. But she testified that she could not hear anyone, and only “assumed” people were talking.

Meanwhile, Ford’s therapist’s notes show that she said there were four boys in the bedroom when she was assaulted. However, she told the Washington Post it was only two, and blamed the error on her therapist. Also, in Ford’s letter to Feinstein she said there were “me and 4 others” at the party. However, in her testimony, she said there were “four boys” at the party in addition to herself and Leland Keyser, her female friend.

Additionally, “Dr. Ford listed Patrick ‘PJ’ Smyth as a ‘bystander’ in her statement to the polygrapher and in her July 6 text to the Washington Post, although she testified that it was inaccurate to call him a bystander. She did not list Leland Keyser even though they are good friends. Leland Keyser’s presence should have been more memorable than PJ Smyth’s,” Mitchell said.

     7. Ford has struggled to recall important recent events relating to her allegations, and her testimony regarding recent events raises further questions about her memory

Mitchell explained that Ford is unable to accurately remember her interactions with the Washington Post, such as what she told reporters or whether or not she provided them with a copy of her therapist’s notes.

Also of significance is Ford’s claim that she wished to remain confidential since she submitted her assault allegations to a person operating the Washington Post’s tip line. She testified that she did this due to a “sense of urgency,” claiming she did not know how to contact the Senate Judiciary Committee. However, she was unable to explain how she knew to contact the offices of Feinstein and Rep. Anna Eshoo (D-Calif.).

Also, Ford cannot recall if she was recorded, via audio or video, during the administration of her polygraph, nor can she remember if the polygraph was administered on the same day as her grandmother’s funeral or the day after.

“It would also have been inappropriate to administer a polygraph to someone who was grieving,” Mitchell said.

  1. Ford’s description of the psychological impact of the event raises questions

Ford testified that she suffers from anxiety, PTSD, and claustrophobia, which explains her fear of flying. However, she testified that she has flown many times in the last year, and flies on a regular basis for her hobbies and work.

Meanwhile, Ford testified that the assault affected her academically in college. However, she never claimed it affected her in high school after the assault allegedly occurred.

“It is significant that she used the word ‘contributed’ when she described the psychological impact of the incident to the Washington Post. Use of the word ‘contributed’ rather than ’caused’ suggests that other life events may have contributed to her symptoms. And when questioned on that point, said that she could think of ‘nothing as striking as’ the alleged assault,” Mitchell explained.

Finally, Mitchell said the “activities of congressional Democrats and Dr. Ford’s attorneys likely affected Dr. Ford’s account.”

And now we are going to have the FBI do an additional investigation after they have already vetted this candidate 6 times. That’s right, 6 times for his other judicial positions!

Besides this expert and witness to the horrible things that the judge has done, the behavior of most of the Democrats especially, but also some of the Republicans really sickens me. It represents childish, uncivil and I think truly unethical behavior, which has no place in this confirmation hearing. Do you all remember all that you did in high school and or college? I doubt it and some of these allegations can be interpreted in various ways. But trust me I am no fan of sexual aggressive behavior on anyone’s part but some of these allegations have to be taken in context and timing and in lieu of the behaviors of the time and grouping behaviors. Really??

I remember college gals exposing themselves when drunk or even after only one or two drinks as well as “men and women” away from home in college who were so drunk that they fell on each other, etc.

But that being what it is I am still angrier with our Senators and Representatives who by their behavior and lack of respect for Judge Kavanaugh and their anger for President Trump have created a circus. All this horrible behavior, the anger, hatred and the vitriol has convinced me to vote for independents and not anyone from each of our popular parties, unless it only leaves me the Republican as my only choice.

I was even going to vote for a Democrat in our Senate race because of the lack of any positive input or suggestions for health care decisions from the two term physician who has filled that spot. But now it will be the independent gentleman who gets my vote. I hope that many of you out there when you get to vote in November carefully make your choices. We the voters are the only people that can turn this black era in our society’s history around. The Democrats are pitting Democrats against Republicans, whites against Afro-Americans, “straights against gays/LGTBXXX and finally men against women. For what?  They want control of our government and to get on with their agenda. Horrifying!!

And now here is another insult by our politicians. I had an interesting experience on Friday afternoon while waiting for our train to New York City. Our Acela train was delayed by 1 ½ hours so that Senator Coons could give interviews in D.C. regarding the Kavanaugh hearing. Yes, they held up the train in D.C. Union Station, so that the senator could complete his interviews and claim the Business Car for him and his troop. Unbelievable!!

Next, more discussion on single payer health care choices and if there are other alternatives to consider.