Now 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!