Category Archives: Affordable Care Act

Surprise medical bills, coronavirus and bad insurance: 3 arguments for Medicare for All’ Really?

As we saw Wednesday the WHO declared the Corona Virus/COID-19 a pandemic. We also heard the President role out plans for travel restrictions, increased testings and economic assistance. But what really gets me angry is that the Democrats in Congress are still making this a political battleground. Shame on them all! This is not the time for partisan politics so that they can embarrass the President and get their wishes and show the evilness of the political hate out there. Grow up Congress and let’s all get in on this battle to keep us all healthy and limit the death toll!! Philip Verhoef of USA Today reported that Congress is grappling with the problem of surprise medical bills, but will its Band-Aid approaches make a difference? As a physician, I’m trained to look beyond superficial symptoms to diagnose the underlying ailment. When patients pay thousands of dollars each year for “good” private insurance, how does a health care system allow them to walk away from a single hospital visit with debilitating medical debt? These concerns have become even more pressing with the spread of the new coronavirus and the costs associated with prevention, testing and treatment.

Most Americans assume that a commercial insurance card in their wallet protects them from unexpected medical bills. They pay their premiums and deductibles, scour the pages of insurance fine print and keep up with the revolving door of “in-network” doctors and hospitals. 

However, going to the “in-network” hospital is no guarantee that the emergency room doctor, radiologist or anesthesiologist will be “in-network.” Today, many hospitals no longer directly employ physicians but instead contract with physician staffing firms such as TeamHealth, which employs more than 16,000 clinicians at 3,300 medical facilities.

Caught unaware in a medical crisis

These agencies are extremely profitable, which is why private equity firms are so hungry to buy them. Contract physicians operate outside of insurance coverage agreements — they’re not part of any “network” — and can act like free agents, billing patients directly for services not covered by insurance, called “balance billing.”  

What does this mean for patients? Imagine you’re having a heart attack and call 911. Paramedics transport you to the nearest emergency room, which may or may not be in your insurer’s network. And because that hospital — or the ER doctor on duty —  does not have a contractual relationship with your insurer, they can essentially name their price and “balance bill” you for the amount the insurance company won’t cover. 

Here in Hawaii, many critically ill patients must use air ambulances for transportation from their home island to one that can provide emergency specialty services. For one of my patients, an air ambulance was a life-or-death necessity but deemed “out of network” by their insurance. Weeks later, the family received a balance bill for more than $25,000. They were forced to file bankruptcy and then enroll in Medicaid to cover subsequent health care costs — all with an insurance card in their wallet.

If this hasn’t happened to you, it’s just a matter of time. Over 40% of privately insured patients face surprise medical bills after visiting emergency rooms or getting admitted to hospitals. These bills punch a major hole in most family budgets: The average surprise hospital bill is $628 for emergency care and $2,040 for inpatient admission. That’s on top of the more than $20,000 families pay in premiums and deductibles each year just for the insurance policy.

If faced with a surprise $500 medical bill, half of Americans would either have to borrow money, go into debt or wouldn’t be able to pay it at all. Medical bills are a key contributor in two-thirds of personal bankruptcies, and yet the vast majority of households filing for medical bankruptcy have insurance. 

Medicare for All is the only solution-Really??

What is the value of commercial insurance if it can’t protect us from financial ruin? 

Lawmakers are considering a number of policies that would prohibit balance billing, cap the amount patients pay at out-of-network facilities and implement baseball-style arbitration when providers and insurance companies can’t agree on a payment. But surprise bills are not the real problem — they are merely one symptom of a dysfunctional system based on private insurance. And insurance companies only turn a profit by restricting patient choice, denying claims and passing costs onto enrollees.

The only policy that can end this scourge for good is single-payer Medicare for All, which would cover everyone in the nation for all medically necessary care. Medicare for All would eliminate out-of-network bills, because every doctor and hospital would be covered. Patients would never see a medical bill again, because Medicare for All would pay doctors and hospitals directly, with no deductibles, co-pays or insurance paperwork to get in the way.

Right now the current Medicare system is covering the costs of coronavirus testing, protecting patients just as it was designed to do. This health emergency is another argument for expanding such protections to all Americans.

Working in various hospitals across the country, I have met so many patients who delay or avoid needed care for fear of surprise bills and financial catastrophe. That’s risky for them and, in the face of a threat like coronavirus, for all of us. It doesn’t have to be this way. As a doctor, I prescribe Medicare for All. 

We are forgetting the huge cost of Medicare for All and the ineffectiveness and short comings of Medicare for All , which I have attempted to point out these last few weeks. Doesn’t any one read my posts?

America’s Health System Will Likely Make the Coronavirus Outbreak Worse

Abigail Abrams noted that as government officials race to limit the spread of the new coronavirus, fundamental elements of the U.S. health care system—deductibles, networks, and a complicated insurance bureaucracy—that already make it tough for many Americans to afford medical care under normal conditions will likely make the outbreak worse.

More than 140 cases of the coronavirus have been confirmed in the United States so far, according to a Johns Hopkins University tracker. But as the CDC makes the test for the virus more widely available, the structure of the U.S. health care system is complicating the response.

For one, people must actually choose to get tested—a potentially expensive prospect for millions of Americans. While the government will cover the cost of testing for Medicaid and Medicare patients, and for tests administered at federal, state and local public health labs, it’s unclear how much patients will be charged for testing at academic or commercial facilities, or whether those facilities must be in patients’ insurance networks. Just recently, a Miami man received a $3,270.75 bill after going to the hospital feeling sick following a work trip to China. (He tested positive for the seasonal flu, so did not have the new coronavirus, and was sent home to recover.)

Those who test positive for COVID-19 possibly face an even more financially harrowing path forward. Seeking out appropriate medical care or submitting to quarantines—critical in preventing the virus from spreading further—both come with potentially astronomical price tags in the U.S. Last month, a Pennsylvania man received $3,918 in bills after being released from a mandatory U.S. government quarantine after he and his daughter were evacuated from China. (Both the Miami and Pennsylvania patients saw their bills decrease after journalists reported on them, but they still owe thousands.)

More than 27 million Americans currently do not have health insurance of any kind, and even more are underinsured. But those who do have adequate health insurance are hardly out of the woods. Many current health plans feature massive deductibles—the amount you have to spend each year before your insurance kicks in. In 2019, 82% of workers with health insurance through their employer had an annual deductible, up from 63% a decade ago, according to a report from the Kaiser Family Foundation. The average deductible for a single person with employer insurance has increased 162% in that time, from $533 in 2009 to $1,396 last year.

More than one quarter of employees, and nearly half of those at small companies, have an annual deductible of at least $2,000. Those who are covered by Obamacare marketplace plans face an even bigger hurdle: the average deductible for an individual bronze plan last year was $5,861, according to Health Pocket, a site that helps consumers shop for health insurance.

For many Americans, paying down an unexpected bill of that size is almost unthinkable. Nearly 40% of U.S. adults say they wouldn’t be able to cover a $400 emergency with cash, savings or a credit card they could easily pay off, according to the Federal Reserve.

Research has shown that even in non-outbreak situations, high deductibles lead people to reduce their spending on health care and delay treatment or prescription drugs, which can pose particularly tough problems for patients with chronic illness or diseases that need early detection. The timing of the new coronavirus at the beginning of the year makes the outlook even worse: because most deductibles reset each January, millions of Americans will be paying thousands out of pocket before their insurance companies pay a cent.

“Most likely most people haven’t started paying down their deductible,” explains Adrianna McIntyre, a health policy researcher at Harvard. “For care they seek, unless it’s covered as zero dollar coverage before the deductible, they could be on the hook for the full cost of their visit, the diagnostic testing and other costs related to seeking care or diagnosis of coronavirus.”

Half of Americans report that they or a family member have put off care in the past because they couldn’t afford it. Others have gone without care because they couldn’t find an in-network provider, or couldn’t determine how much care would cost in advance, so decided not to risk seeking medical attention.

“When patients try to go to a doctor or hospital, they often don’t know how much it’s going to cost, so they get a bill that’s way more than expected,” says Christopher Whaley, a health economist at the RAND Corporation. “On a normal basis, that’s chaotic and challenging for patients. But when you add on top this situation where you have a potential pandemic, then that’s even worse.”

In the face of that kind of uncertainty, many patients may simply decide not to go to the doctor, he added, which is “exactly the opposite of what we want to happen in this type of situation.”

Public health experts and Democrats have also criticized the Trump administration’s decision to allow people to sidestep the Affordable Care Act’s rules and buy limited, short-term health insurance coverage. Such “junk plans,” said Senator Patty Murray, speaking at a Senate Health, Education, Labor and Pensions Committee hearing on Wednesday, are not required to cover diagnostic tests or vaccines.

The Trump administration’s embrace of such barebones plans “makes it much harder for people to get the care they need to keep this crisis under control,” she said. A large group of health, law and other experts also released a letter this week urging policymakers to “ensure comprehensive and affordable access to testing, including for the uninsured.”

Insurance industry trade group America’s Health Insurance Plans issued guidance on the coronavirus last week, but it did not recommend that insurance companies eliminate out-of-pocket costs related to the virus. It said insurers would be working with the CDC and “carefully monitoring the situation” to determine “whether policy changes are needed to ensure that people get essential care.”

New York Governor Andrew Cuomo issued a directive on Monday requiring New York health insurers to waive cost sharing for testing of the coronavirus, including emergency room, urgent care and office visits. This could help New Yorkers who receive coverage through Medicaid and other state-regulated plans, but it won’t apply to the majority of employer-based health insurance, which is regulated by the federal government. Other states have similar limitations on the insurance plans they can regulate, according to McIntyre.

The federal government, on the other hand, could step in. The Trump Administration is considering using a national disaster recovery program to reimburse hospitals and doctors for treating uninsured COVID-19 patients. And even Republicans, who have traditionally opposed health care paid for by the government, are warming to the idea. “You can look at it as socialized medicine,” Florida Rep. Ted Yoho, who has vocally opposed the Affordable Care Act, told HuffPost this week. “But in the face of an outbreak, a pandemic, what’s your options?”

But even if the federal government takes steps to eliminate deductibles or other cost-sharing related to the coronavirus, experts say that Americans should brace themselves for long wait times to see providers, or for having to see doctors who are out-of-network, due to the limited capacity of providers and hospitals.

Those who don’t need to be treated at a hospital may still be impacted. The CDC has recommended that people maintain a supply of necessary medications in case they are quarantined, for example. But many insurance companies do not allow patients to refill prescriptions until they are almost out. The CDC also recommends that people to stay home from work if they experience symptoms of respiratory illness, but a lack of federally mandated sick leave makes it impossible for many workers to afford to take time off.

These consequences of the country’s fragmented health care system become more visible in times of stress, says Whaley. “In a pandemic type situation, that’s harmful both for patients,” he says, “and also for the members of society.

”Coronavirus: US ‘past the point of containment’ in battle to stop outbreak spreading

Tim Wyatt reported that America is “past the point of containment” in its battle against the coronavirus, senior health officials have admitted.

There are now more than 550 confirmed cases of the virus in the United States and at least 22 deaths linked to the outbreak.

Now, the government’s strategy had to change from trying to hold the virus at bay to actively seeking to minimise its impact and slow its spread, experts said.

Speaking on US television, the former commissioner of the Food and Drug Administration Dr Scott Gottlieb, said everything had changed.

“We’re past the point of containment. We have to implement broad mitigation strategies. The next two weeks are really going to change the complexion in this country.

“We’ll get through this, but it’s going to be a hard period. We’re looking at two months, probably, of difficulty.”

A similar message came from the Surgeon General Jerome Adams who warned it was time to consider cancelling large gatherings, including sporting events, and closing schools.

Each community might take a different approach to mitigating Covid-19, but inaction was not longer an option he cautioned while speaking to CNN. “Communities need to have that conversation and prepare for more cases so we can prevent more deaths,” he said.

Those in the most at-risk groups, including the elderly or unwell, should refrain from spending time in confined spaces with large numbers of the public, Dr Adams added.“Average age of death for people from coronavirus is 80. Average age of people who need medical attention is age 60. “We want people who are older, people who have medical conditions, to take steps to protect themselves, including avoiding crowded spaces, including thinking very carefully about whether or not now is the time to get on that cruise ship, whether now is the time to take that long haul flight,” he said.

Dr Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, echoed this advice. “If you are an elderly person with an underlying condition, if you get infected, the risk of getting into trouble is considerable,” he told NBC.“So it’s our responsibility to protect the vulnerable. When I say protect, I mean right now. Not wait until things get worse. Say no large crowds, no long trips. And above all, don’t get on a cruise ship.”

A swathe of conferences, including many tech-focused events in California, have already been cancelled over fears flying in thousands of delegates from across the country and world would exacerbate the spread of Covid-19. Some schools in the US are already closing, with major sporting events such as the Indian Wells tennis tournament being cancelled.

The comments from senior Trump administration health officials marks a shift from an earlier tone of calm. Several people, including the president, had sought to downplay fears about the coronavirus, insisting it probably would not turn into a full-blown epidemic in America.

Dr Fauci even suggested limited lockdowns could be imposed on regions or towns where a serious outbreak occurs, saying the government was ready to take “whatever action is appropriate” to try and mitigate the crisis.’We’re gearing up for something extremely significant’: 

Top hospitals across the US told us how they’re preparing for the coronavirus outbreak

Lydia Ramsey and Zachary Tracer reviewed the U.S. hospitals preparation for this pandemic. Hospitals around the US are preparing for the novel coronavirus outbreak, which has sickened more than 200 people in the US and 100,000 worldwide.

They want to make sure workers and equipment are ready to go in the event of a worst-case scenario. “We’ve not yet seen an epidemic or pandemic in our lifetimes of this size and scope,” said Becca Bartles, the executive director of infectious disease prevention at Providence St. Joseph Health System. “We’re gearing up for something extremely significant.”

When the first case of novel coronavirus showed up in the US in January, Becca Bartles was ready for it. 

As the executive director of infectious disease prevention at Providence St. Joseph Health System, she had been preparing for years. Bartles helps prepare Providence, which runs 51 hospitals across the West Coast, for potential outbreaks by keeping an eye out for new pathogens that could hit the communities the health system serves. 

“We’ve not yet seen an epidemic or pandemic in our lifetimes of this size and scope,” Bartles said.  “We’re gearing up for something extremely significant.”

Hospitals and healthcare workers are already starting to feel the effects of the coronavirus outbreak as it hits communities around the US. The US has reported more than 200 cases of the novel coronavirus, which causes the disease known as COVID-19.  More than 100,000 people have come down the virus worldwide, mainly in China.

And they’re preparing for the outbreak to get worse. Some of the hospitals Bartles works with are in the Seattle area and are already treating coronavirus patients. She said the virus is positioned to be the biggest outbreaks we’ve seen in recent US history.

‘It will stretch our capacity to provide healthcare overall in the US’

“I don’t think we can appreciate, based on what we’ve seen in our lifetimes, how big that’s going to be,” Bartles said. “That does cause me significant concern.” “It will stretch our capacity to provide healthcare overall in the US,” she added.

According to the US Centers for Disease Control and Prevention, reported symptoms related to the novel coronavirus include fever, cough, and shortness of breath, appearing within 14 days of exposure to the virus.

In a presentation hosted by the American Hospital Association, which represents thousands of hospitals and health systems, one expert projected there could be as many as 96 million cases in the US, 4.8 million hospitalizations, and 480,000 deaths associated with the novel coronavirus. The American Hospital Association said the webinar reflects the views of the experts who spoke on it, not its own. 

Preparing for the worst 

Health systems like Providence perform drills and trainings in anticipation of outbreaks like the novel coronavirus. The goal is to make sure employees, especially those working in the emergency department or who might care for critically ill patients, are trained correctly and have the right protective equipment.

And they’re ramping those up now. In Philadelphia, Jefferson Health has been conducting extra protective-equipment trainings, focused on intensive care unit clinicians who might treat people with the coronavirus.

The 14-hospital system also started a coronavirus task force this week and is readying its outbreak plans. The idea is to prepare for a worst-case scenario.

“We’re saying, look, let’s plan as if there’s going to be a lot of cases, it’s going to be overwhelming to our hospital,” said Dr. Edward Jasper, an emergency medicine physician who leads the task force. “We don’t think that’s going to happen. And then whatever else comes, it’s going to be nothing compared to that. So we’re prepared.”

For now, Jasper said he’s not expecting the worst. “We watch it so closely and right now it’s not triggering keeping me awake at night,” he said.

At Providence, Bartles said leaders within the organization are now meeting multiple times a day to discuss issues like making sure the hospitals have enough supplies on hand, especially protective equipment for those working in emergency departments. 

The goal of the meetings is also to inform other hospitals across Providence’s network of what’s going on in Washington, which has been hit hard with the virus. 

How the largest health system in New York is preparing

The senior leadership at New York’s Northwell Health System, which operates 23 hospitals, has been meeting continuously for the last several weeks, chief quality officer Dr. Mark Jarrett told Business Insider.  The discussions cover what happens if one individual comes in with symptoms all the way to a pandemic. 

Northwell’s relying on some of the preparation it did in advance of the SARS epidemic in 2003, and its response to the H1N1, or Swine Flu pandemic in 2009. But, Jarrett said, the hospital has changed a lot since then.  Northwell, New York’s largest health system by revenue and the state’s largest private employer, has been steadily moving more of its services outside the four walls of a hospital. 

That means the health system will have to account for patients showing up for care in places other than the main hospital in a community — places like urgent care centers and primary care clinics.

Readying hospitals for a surge of patients

Should the outbreak intensify, hospitals are grappling with how to prepare for the surge in coronavirus patients while also keeping other patients safe. At first, hospitals will isolate patients with the coronavirus, but if lots of patients come down with the virus, hospitals will probably put them in rooms together, said Kelly Zabriskie, Jefferson’s director of infection prevention.

Dr. Kathleen Jordan, a vice president at CommonSpirit Health, a 142-hospital health system and chief medical officer at the system’s Saint Francis Memorial Hospital, told Business Insider that the health system is having conversations about what might happen if they’re confronted with an influx of patients. 

That might include setting up tents, building out larger emergency rooms or adding more beds for patients who need to stay at the hospital. For now, the health system has a few cases of the novel coronavirus under investigation.  Eventually, hospitals might have to consider reducing or pausing elective procedures to make room for the surge in patients, Northwell’s Jarrett said.  Hospitals are also thinking about staff being out, either due to the virus itself, or in the event that they have to care for their family.

Northwell on Tuesday told its employees that it’s restricting travel for business both internationally and domestically through the end of March. That’s a move other hospitals are making as well. “These updated travel guidelines are designed to help us remain in good physical health so we can most effectively care for the patients and families we serve,” Northwell said in an email to employees.  

But you shouldn’t rush to the emergency room if you start having flu symptoms.  Bartles said the plan is to focus on following CDC recommendations. As the virus continues to spread in communities, it will be harder to distinguish what might be flu from coronavirus. 

Jan Emerson-Shea, a spokeswoman for the California Hospital Association, said hospitals are encouraging patients to call ahead or use an online doctor visit, rather than show up to an emergency room with potential coronavirus. That can help prevent them from infecting others, and let hospitals focus their resources on the most serious cases.

And lastly, few have mentioned that in China they are already taking down some of the temporary housing for the quarantined patients as the infection rate decreases. Important to note as we prepare for the worst!

And next week we should discuss the economic issues resulting from the pandemic!

Can You Afford To Get Coronavirus? How to Prepare for the Virus andHow The U.S. Healthcare System Is Failing Us

This is a lengthy post but with all the fear regarding COVID-19 I thought that it would be worth the time. I became more aware as we traveled to the West Coast for a half marathon at Napa Valley. There were many people on our planes wearing masks and my wife was so worried about our planned trip to Europe in April.  The cruise companies now our offering  to either give one hundred percent refund or hold the paid fees for 2 years to allow rescheduling of the cruises.  Can you imagine what the Corona Virus scare is doing to economies around the world>

Sarah Midkiff reported that as the deadly coronavirus outbreak approaches pandemic status, the U.S. government remains in the midst of approving legislation for a $7.5 billion emergency spending bill. Meanwhile, coronavirus continues its spread in the U.S. — with 100 confirmed cases and six deaths across 15 states — so the need for these funds is more imperative than ever. The emergency bill will allocate money to the Department of Health and Human Services for vaccine development, protective and medical equipment, and aid for state and local governments affected by an outbreak, according to the Washington Post.

But, what legislators have yet to mention is whether subsidizing treatment or funding low-cost and free clinics will be part of the plan. The bill may address availability of vaccine development, but it does not directly address affordability of testing or treatment, which is of the utmost importance during a pandemic.

A report published by America’s Health Insurance Plans (AHIP) on Thursday stated that the Centers for Disease Control and Prevention (CDC) is currently the only facility equipped to test for COVID-19. The CDC is not billing for testing, but the test itself isn’t the only line item on a possible medical bill. There is the cost of the doctor’s visit; other tests they might run in conjunction with COVID-19, such as standard flu tests; treatment and medication, as well as getting the vaccine when it becomes available. And, medical bills can grow astronomically high if someone requires in-patient care, like an overnight stay in the hospital.

Stories have already begun to emerge of Americans seeking testing only to find that their insurance was insufficient to the tune of thousands of dollars in medical bills. One such example is a man in Florida who faces a $3,270 medical bill after he went through his insurance when he was concerned he might have been exposed to coronavirus. He was confirmed negative for COVID-19 after testing positive for the flu via a standard flu test rather than the more expensive CT scan which has been proven to be the most consistent test in diagnosing coronavirus.

Others have undergone government-mandated treatment and found that, despite the procedure being required, they were the ones left to foot bills that totaled thousands of dollars. Experiences like this make it easy to see why a 2018 national poll conducted by West Institute and NORC at the University of Chicago found that 44% of Americans declined to see a doctor due to cost.

Notably, the U.S. is alone among other developed countries as the only one that doesn’t offer federally mandated paid sick leave. This makes it particularly difficult to follow the CDC’s current advice that people experiencing even mild respiratory symptoms should stay home, other than when getting medical care. Between a lack of mandated paid sick leave and approximately 27 million Americans currently without health insurance, the coronavirus outbreak is at risk of exhausting our already failing public health system.

Even among people with health insurance, 29% are underinsured, according to results from a 2018 Commonwealth’s Fund survey, meaning that even though they technically have an insurance plan, the copays and deductibles make seeking care unaffordable in relation to their income. Cases of the virus could go undetected and untreated simply because Americans cannot afford to be saddled with medical debt or go without pay to take sick leave (or both), thus encouraging a rapid spread of the virus as people attempt to “power through” in spite of symptoms.

And then there are the approximately 11 million undocumented U.S. residents: Many of these people are un- or under-insured, and also have to grapple with the justified fear of coming into contact with federal authorities, therefore preventing them from seeking medical care.

If further evidence is needed that our health care system has been crippled by privatization, government officials are not debating whether or not pharmaceutical companies should be allowed to profit from a vaccine, but are just figuring out by how much. Last week, the Department of Health and Human Service secretary, Alex Azar, would not commit to price controls on a coronavirus vaccine. “We need the private sector to invest… price controls won’t get us there,” said Azar.

House Speaker Nancy Pelosi responded directly to Azar’s comments. “This would be a vaccine that is developed with taxpayer dollars…We think that should be available to everyone—not dependent on ‘Big Pharma,’” she said in a press release on February 27. She described the vaccine as needing to be “affordable,” but what does that even mean? What is affordable to some is not affordable to all. 

Still, a vaccine – affordable or not – is a ways off. In a coronavirus task force briefing with Donald Trump on Monday, experts estimated that it would take a year to a year-and-a-half before a vaccine would be effective and safe for the public, reports CNN. Until then, the economic inequality that runs rampant in America is bound to be reflected in who can afford to survive this epidemic, and who can’t.

US may pay for uninsured coronavirus patients

Washington (AFP) – The US may invoke an emergency law to pay for uninsured patients who get infected with the new coronavirus, a senior health official said Tuesday.

Public health experts have warned that the country’s 27.5 million people who lack health coverage may be reluctant to seek treatment, placing themselves at greater risk and fueling the spread of the disease.

Robert Kadlec, a senior official with the Health and Human Services department told the Senate on Tuesday that talks were underway to declare a disaster under the Stafford Act, which would allow the patients’ costs to be met by the federal government.

Under this law, their health care providers would be reimbursed at 110 percent of the rate for Medicaid, a government insurance program for people with low income, he added.

“We’re in conversations, initial conversations with CMS (Centers for Medicare & Medicaid Services) to understand if that could be utilized in that way and be really impactful,” Kadlec told a Senate committee.

President Donald Trump also touched on the issue as he headed to a briefing on the coronavirus outbreak at the National Institutes of Health in Washington on Tuesday.

“We’re looking at that whole situation. There are many people without insurance,” Trump told reporters.

The number of Americans without health insurance began falling from a high of 46.5 million in 2010 following the passage of Obamacare (the Affordable Care Act).

It climbed again to 27.5 million in 2018, or 8.5 percent of the population, from 25.6 million the year before.

The reasons include policies by Trump’s administration that made it harder to enroll in Medicaid — such as adding requirements to work — or to sign up for insurance under the marketplaces created by Obamacare.

The Republican-held Congress also repealed a penalty on people who lack insurance, which may have led people to voluntarily drop out.

The Centers for Disease Control and Prevention (CDC) has said patients who are advised by their health care providers to stay at home should do so for at least two weeks, but a work culture that emphasizes powering through while sick could compound the problem further.

The US is alone among advanced countries in not offering any federally mandated paid sick leave. While some states have passed their own laws, 25 percent of American workers lacking any whatsoever, according to official data.

Maia Majumder, an epidemiologist at Harvard, told AFP she was particularly concerned by low-wage workers in the service and hospitality sector, who cannot afford to take time off but could act as vectors to transmit the spread of the disease.

The latest coronavirus death rate is 3.4% — higher than earlier figures. Older patients face the highest risk.

The global death rate for the novel coronavirus based on the latest figures is 3.4% — higher than earlier figures of about 2%.

  • In contrast, the seasonal flu kills 0.1% of those infected.
  • A patient’s risk of death from COVID-19 varies depending on age and preexisting health conditions.
  • Though the latest numbers mark an increase in mortality, experts have predicted that the fatality rate of COVID-19 could decrease as the number of confirmed cases rises.

The latest global death rate for the novel coronavirus is 3.4% — higher than earlier figures of about 2%. 

The coronavirus outbreak that originated in Wuhan, China, has killed more than 3,100 people and infected nearly 93,000 as of Tuesday. The virus causes a disease known as COVID-19.

Speaking at a media briefing, the World Health Organization’s director-general, Tedros Adhanom Ghebreyesus, noted that the death rate was far higher than that of the seasonal flu, which kills about 0.1% of those infected.

The death rate is likely to change further as more cases are confirmed, though experts predict that the percentage of deaths will decrease in the longer term since milder cases of COVID-19 are probably going undiagnosed.

“There’s another whole cohort that is either asymptomatic or minimally symptomatic,” Anthony Fauci, the director of the US National Institute of Allergy and Infectious Diseases, said at a briefing last month. “We’re going to see a diminution in the overall death rate.”

‘It is a unique virus with unique characteristics’

Tedros noted differences between the novel coronavirus and other infectious diseases like MERS, SARS, and influenza. He said the data suggested that COVID-19 did not transmit as efficiently as the flu, which can be transmitted widely by people who are infected but not yet showing symptoms. 

He added, however, that COVID-19 caused a “more severe disease” than the seasonal flu and explained that while people around the world may have built up an immunity to the flu over time, the newness of the COVID-19 meant no one yet had immunity and more people were susceptible to infection. 

“It is a unique virus with unique characteristics,” he said. 

Tedros said last week that the mortality rate of the disease could differ too based on the place where a patient receives a diagnosis and is treated. He added that people with mild cases of the disease recovered in about two weeks but severe cases may take three to six weeks to recover.

Older patients face the highest risk 

A patient’s risk of dying from COVID-19 varies based on several factors, including where they are treated, their age, and any preexisting health conditions.

COVID-19 cases have been reported in at least 76 countries, with a vast majority in China. 

A study conducted last month from the Chinese Center for Disease Control and Prevention showed that the virus most seriously affected older people with preexisting health problems. The data suggests a person’s chances of dying from the disease increase with age.

Notably, the research showed that patients ages 10 to 19 had the same chance of dying from COVID-19 as patients in their 20s and 30s, but the disease appeared to be much more fatal in people ages 50 and over. 

About 80% of COVID-19 cases are mild, the research showed, and experts think many mild cases haven’t been reported because some people aren’t going to the doctor or hospitals for treatment. 

CDC reports 108 cases of coronavirus, including presumed infections; 4 more deaths

The Centers for Disease Control and Prevention (CDC) on Tuesday confirmed 17 new cases of the coronavirus and four more deaths due to the outbreak, bringing the total number of U.S. cases to 108, including among repatriated citizens.

Coronavirus is making some Republicans reconsider the merits of free health care

Tim O’Donnell reported that the Coronavirus has a lot of people re-thinking things. That apparently includes Republicans and government-funded health care.

With the possibility of an outbreak of the respiratory virus in the United States looming, the government is still trying to piece together its response. And it sounds like free testing could be on the table. Rep. Ted Yoho (R-Fla.), at least, thinks it’s really the only option. Yoho is normally known for opposing the Affordable Care Act, and certainly doesn’t seem likely to advocate for Medicare-for-All anytime soon. But he’s willing to blur the lines when an unforeseen circumstance like coronavirus comes to town and is even ok if you want call it “socialized medicine.”

Truly stunning to hear some Republicans advocate for free Coronavirus testing and treatment for the uninsured.

Rep. Ted Yoho (R-Fla.), one of the most anti-ACA members:

“You can look at it as socialized medicine, but in the face of an outbreak, a pandemic, what’s your options?”

The Trump administration, meanwhile, is contemplating funding doctors and hospitals so they can care for people who don’t have insurance should they become infected with the virus, a person familiar with the conversation told The Wall Street Journal. Read more at The Wall Street Journal.

The Coronavirus Outbreak Could Finally Make Telemedicine Mainstream in the U.S.

Time’s reporter, Jamie Ducharme noted that for years, telemedicine has been pitched as a way to democratize medicine by driving down costs, increasing access to care and making appointments more efficient. It sounds great—until you look at the data, and find that only about 10% of Americans have actually used telemedicine to make a virtual visit, according to one 2019 survey.

An outbreak of the novel coronavirus COVID-19 could change that. If extreme measures like mass quarantines come to pass, telehealth could finally have its bittersweet moment in the spotlight, potentially generating momentum that proponents hope will continue once life returns to normal.

“Something like having to stay home could springboard telehealth tremendously, because when we get over this—and we will—people will have had that experience, and they’ll be saying, ‘Well, why can’t I do other aspects of my health care that way?’” says Dr. Joe Kvedar, president-elect of the American Telemedicine Association (ATA).

As of March 3, more than 92,000 people worldwide have been sickened by the virus that causes COVID-19, including more than 100 in the U.S. As both numbers trend upward, the U.S. Centers for Disease Control and Prevention (CDC) has warned that increased person-to-person spread in U.S. communities is likely, and that containment measures may become increasingly disruptive to daily life. If the situation reaches the point where public health officials are encouraging or requiring people to stay home, the health care system may have to offer many medical appointments via telehealth services, the CDC’s Dr. Nancy Messonnier said during a Feb. 26 press briefing.

Kvedar says telehealth tools offered by health plans, private companies and pharmacies are ready and waiting for that possibility. There are some limitations to telehealth’s utility for COVID-19 testing—you can’t take a chest x-ray or collect a sample for lab testing remotely, after all—but Kvedar says it could be used for initial symptom assessment and questioning, as well as non-virus-related appointments that couldn’t happen in person due to precautions. If a patient turned up at an emergency room with possible COVID-19 symptoms, doctors could also do initial intake via virtual platforms, while keeping the patient in isolation to minimize spread within the vulnerable health care environment, he says.

Telehealth giants like Amwell and Teladoc are now advertising their availability for coronavirus-related appointments, and Teladoc’s stock prices spiked in late February. XRHealth, a company that makes health-focused virtual reality applications, is this week providing Israel’s Sheba Medical Center with VR headsets that will both allow doctors to monitor COVID-19 patients remotely, and enable quarantined patients to “travel” beyond their rooms using VR, says XRHealth CEO Eran Orr. The company will next week begin working with hospitals to deploy the technology in the U.S., Orr says.

All of these solutions seem logical. But in practice, there’s a “thicket of state laws and regulations that make telemedicine very complex…to implement broadly,” says Dr. Michael Barnett, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. Insurers—especially Medicare—don’t always cover telehealth visits, and, since medical licenses are state-specific, there could be legal issues if a doctor is located in a different state than the patient they’re treating, Barnett says. Drug prescription and privacy laws can also complicate regulation, according to the American Hospital Association.

These regulatory issues, as well as a lack of patient awareness, have kept telehealth from being as widely adopted as it could be, Barnett says. COVID-19 could be “a good use case” for telemedicine, he says, but it will partially depend on lawmakers’ willingness to relax, or at least streamline, regulation.

The wheels are already in motion. On Feb. 28, telehealth groups including the ATA, the Personal Connected Health Alliance and the eHealth Initiative sent a letter to Congressional leaders, urging them to expand access to telehealth and to grant the Department of Health and Human Services the power to let Medicare cover telemedicine appointments during emergency situations. On March 3, Arizona Rep. Ruben Gallego announced he was introducing a bill that would allow Medicaid to cover all COVID-19-related charges, including virtual appointments.

That’s a good step, but Julia Adler-Milstein, director of the University of California, San Francisco’s Center for Clinical Informatics and Improvement Research, says there are still logistical challenges.

She says larger health systems that have invested heavily in telehealth, like Kaiser Permanente, have seen benefits from it, but providers with a less built-out infrastructure will have to grapple in real-time with questions like, “How do we know which patients are well-suited to telehealth?” and “How do we get their information into the doctor’s hands?” These issues are especially salient for patients with complex medical histories, who may have choose between seeing their regular doctor in person, potentially risking infection, or seeing a doctor virtually who does not have access to their medical records, she says.

Kvedar acknowledges that widespread adoption of telehealth during the COVID-19 outbreak may require some goodwill on the part of companies and doctors. Companies like CVS and Walgreens could waive fees for the use of their telemedicine services during the crisis, Kvedar suggests, or doctors could offer to see patients virtually for free for a few hours a week. “People pull together for all sorts of things,” he says.

Barnett is less optimistic that providers can seamlessly overcome regulations, but says patients and doctors will find a way through the outbreak with or without telemedicine, even if it means conducting many appointments over the old-fashioned telephone. “We have more pressing needs in this epidemic,” he says, “than telehealth availability.”

15 Italian tourists test positive for Covid-19, India springs into battle mode

Niharika Sharma reported that fifteen Italian tourists in India have been reportedly tested positive for the dreaded coronavirus, perhaps finally bringing home the full scale of the seriousness of the global health crisis to the country.

This is besides the six others who have been diagnosed with Covid-19 across the country, prompting India to take massive preventive measures.

The Italian tourists have been quarantined at a camp of the paramilitary, Indo-Tibetan Police Force, media reports said.

Fear and anxiety gripped India’s national capital region (NCR) after a 45-year-old man was diagnosed with the novel coronavirus infection in the city yesterday (March 3). This prompted authorities to step up the vigil.

Over 40 people in Delhi NCR, who came in contact with the patient, are under surveillance. Another 13 people have been screened in Uttar Pradesh’s Agra where he visited his family.

The man who self-reported at Delhi’s Ram Manohar Lohia Hospital had organised his son’s birthday party at Hyatt Regency on Feb. 28. The five-star hotel has asked staffers, who were on duty that day, to stay at home. “The hotel has also started to conduct daily temperature checks for all colleagues and contractors when they enter and exit the building,” the hotel said in a statement yesterday (March 3).

The school in Noida where the infected man’s son attended classes has been shut for the rest of the week, and five students are being screened.

Besides the Delhi man, an Italian tourist, and a person in Hyderabad, who travelled from Dubai to Bengaluru on Feb. 20 on an IndiGo flight, have also tested positive for the virus. ”We’re following all prescribed Airport Health Organisation guidelines,” IndiGo said in a statement yesterday. The airline has asked its four cabin crew who were on the aircraft to stay at home.

On guard

Authorities appear to be working overtime to track the footprints of all the patients and screen everyone who came in contact with them. “Our officers even visit the homes individually, taking necessary precautions, to check listed people for symptoms,” an official of the Integrated Disease Surveillance Programme (IDSP) under the health ministry told Hindustan Times on condition of anonymity. “For asymptomatic people, home quarantine for a stipulated period of time is good enough, but those who develop symptoms are moved to a hospital as per protocol.”

But the process could be tedious as the 69-year-old Italian tourist, who was tested positive in Jaipur on March 3,had travelled to six districts in India before arriving at Rajasthan. He and his wife, who has also tested positive, were part of a 21-member group, which landed in Delhi on Feb. 21. The rest of the group is in Agra, according to a Hindustan Times report.

The health ministry has now issued a travel advisory, suspending all regular visas/e-visas granted on or before March 3 to nationals of Italy, Iran, South Korea, and Japan, who have not yet entered India. The advisory also suspends visa on arrival issued until March 3 to Japanese and South Korean nationals who have not yet entered India.

The government has also made it mandatory for passengers entering India from other countries affected by coronavirus to fill forms with personal details and travel history to the health and immigration officials at 21 airports across the country and 12 major and 65 minor seaports.

Aviation watchdog Directorate General of Civil Aviation has also asked carriers to ensure that adequate protective gears like surgical masks and gloves are available in flight for passengers.

In Delhi, the Kejriwal government has reserved 230 beds in isolation wards at 25 hospitals and also sent advisories to schools mentioning precautions to tackle the situation.

On March 3, the information ministry asked all private radio and TV channels to give “adequate publicity” to the travel advisory issued by the health ministry in the wake of the coronavirus outbreak.

The health ministry has also launched a series of TV commercials as part of its awareness program against the outbreak.

Here’s what you must keep in mind:

In addition, the Narendra Modi government has asked the army, the navy and the air force to prepared quarantine facilities for over 2,500 in coming days, as per the sources quoted by various media reports.

Preventive measures

Several events, where foreign delegates were expected to participate, have been cancelled or postponed.

The Indian Navy called off a multilateral naval exercise that was scheduled from March 18 in Visakhapatnam due to coronavirus. Around 30 countries were expected to take part in the event.

On March 3, Chinese smartphone maker Xiaomi said it is cancelling all upcoming on-ground launch events in India to reduce exposure risk in the wake of Covid-19.

Italy could have more than 100,000 coronavirus cases, expert warns

Reporter Will Taylor of the Yahoo News noted that Italy could have more than 100,000 cases of coronavirus, an expert has revealed.

Professor Neil Ferguson, of Imperial College London’s faculty of medicine, said he estimates there are “at least” 50,000 to 100,000 cases of the virus in the country, which is one of the worst affected by the virus.

Italy has 2,500 confirmed cases and has suffered 79 deaths.

Prof Ferguson told the BBC’s Today programme that he expects to see measures to tackle the virus rolled out in a matter of days.

“[Italy has] I think it’s over 50 deaths now,” he said, “so those people were probably infected three weeks ago, and for every person who dies we think there might be 100, maybe even 200 people infected.

“The lethality of this virus is not completely determined but it’s in that order… so the epidemic is probably doubling every week or so in Italy, so when you put those numbers together, we’d estimate somewhere between 50,000 and 100,000 cases at the moment in Italy.

“At least, it could even be higher, cases may still be being missed even in severe cases.”

He said the UK is “several weeks” behind Italy and is in an earlier stage of an epidemic.

Authorities will be looking to slow the spread of the virus to try to relieve pressure on health systems and the UK government yesterday announced measures to tackle the virus.

Prof Ferguson said screening air passengers is imperfect and pointed out that Spanish flu spread around the world in the days before commercial air travel.

His figures mean the total number of Italy’s cases could outstrip the total number confirmed worldwide. Just over 93,000 have been reported globally as of Wednesday morning.

After mainland China – where the virus originated – South Korea is the next worst hit with 5,328 confirmed cases and 28 deaths.

Iran reports 77 deaths from its 2,300 officially reported cases.

A Coronavirus Guide for Older Adults (And Their Family Advocates)

Jeffrey Kluger noted that it’s hard enough getting old, what with all of the creeping ailments—diabetes, COPD, dementia, heart disease—that come along with age. Now add a novel coronavirus to the mix. There are more than 91,000 COVID-19 cases and 3,100 deaths as of writing, but the virus doesn’t hit all demographics equally hard—and seniors are the most vulnerable.

A late February study in the Journal of the American Medical Association showed that children 10 and under accounted for just 1% of all COVID-19 cases, for example, while adults in the 30-79 age groups represented a whopping 87%. The World Health Organization (WHO) found something similar in China, with 78% of patients falling between the ages of 30 and 69.

The older you get, the likelier you are not only to contract a SARS-CoV-2 infection (the virus that causes COVID-19), but to suffer a severe or fatal case. One study out of China found that the average age of COVID-19 patients who developed acute respiratory distress syndrome—a severe shortness of breath often caused by fluid in the lungs and requiring a ventilator—is 61. As early as January, Chinese health authorities were already reporting that the median age range for people who died of the disease was 75.

“Older people are more likely to be infected, especially older people with underlying lung disease,” says Dr. Teena Chopra, medical director of infection prevention and hospital epidemiology at Wayne State University. “For this population, mortality rates for COVID-19 are about 15%.”

In this sense, COVID-19 behaves a lot like seasonal flu. From 70% to 85% of all flu deaths and 50% to 70% of flu-related hospitalizations occur among people in the 65-plus age group, according to the United States Centers for Disease Control and Prevention (CDC). The 2002-2003 SARS outbreak similarly proved lethal for more than 50% of people over 60 who contracted the disease..

None of this is a surprise of course. With their higher risk of underlying health conditions, older people are already under physical stress, and their immune systems, even if not significantly compromised, simply do not have the same “ability to fight viruses and bacteria,” says Dr. Steven Gambert, professor of medicine and director of geriatrics at the University of Maryland School of Medicine.

What’s more, seniors’ risk of exposure to any pathogen is often higher than that of other adults. There are 48 million seniors overall in the U.S., and while only about 3% of them reside in assisted living facilities, that still factors out to more than 1.4 million already at-risk people living in communal environments in which disease can spread quickly.

“People living in long care facilities have common meetings, they share common rooms,” says Chopra. Common meetings and common rooms can too often mean common pathogens.

In the event of coronavirus infection in a residential facility, Gambert says, those living there should avoid communal rooms and even meals, and, if possible, eat in their own rooms.

Even older people living at home face communal risks, since many of them regularly visit community senior centers, which are great places for socialization and provide a means to stay active and engaged, but can serve as pathogenic petri dishes. Gambert recommends being proactive in these situations, asking the staff of the senior center if they have had any cases of coronavirus, and if so, avoid those facilities.

The health system itself may be playing a significant role in putting seniors at risk. People with multiple medical conditions typically visit multiple specialists, and every such visit means entering a health care environment that can be teeming with viruses and bacteria. For now, Chopra advises older patients to postpone doctor visits that aren’t absolutely essential, like “their annual eye visit. Dental cleaning can be avoided too.” Telemedicine—conducting doctor visits that don’t require hands-on treatment online—can be helpful too, as can e-prescribing, with drugs being delivered straight to patients, sparing them exposure to pharmacies.

Staying current on vaccines—especially flu and pneumonia—can also be critical. Patients—or their family advocates—should ask doctors if they are up to date on their vaccines, or if they need a booster, especially since vaccine formulations change and improve over time. “If you haven’t had a pneumonia vaccine now is the time to get one,” says Gambert. “Even if you have had one in the past, ask your primary care provider if you need a newer one.”

Finally, it’s important to remember that the way COVID-19 presents itself in a younger person is not always the way it presents itself in someone who’s older. “Old people may not get a fever so just checking their temperature may not reveal the infection,” says Gambert.

Instead, he says, families and seniors should be alert for “atypical presentation” of COVID-19. A fall or forgetfulness, for example, might be a sign of infection, even if other, more common symptoms aren’t in evidence. “Any reason you don’t feel the same as you usually do should not be dismissed,” Gambert says.

The coronavirus epidemic is not going away any time soon. That means continued vigilance for our own health and special vigilance for that of seniors. The people who looked after us when we were younger need the favor returned now that they are older.

AOC says that ensuring access to free coronavirus testing and treatment is ‘absolutely’ an ‘argument for Medicare for All’

According to Joseph Zeballos-Roig AOC told the Huffington Post that the government is taking steps to guarantee free coronavirus testing and medical treatment.

“What this crisis has taught us is that, our health care system and our public health are only as strong as the sickest person in this country,” she told the outlet.

Concerns are increasing that the expensive nature of American healthcare could discourage people from seeking medical treatment if they are infected with the coronavirus.

Democratic Rep. Alexandria Ocasio-Cortez  said in an interview published Tuesday that ensuring free coronavirus testing and medical treatment is “absolutely” an “argument for Medicare for All.”

The New York congresswoman told the Huffington Post that if the government took steps to guarantee public access to testing and treatments by paying for it, “then what makes coronavirus different from so many other diseases, particularly ones that are transmissible?”

“What this crisis has taught us is that, our health care system and our public health are only as strong as the sickest person in this country,” she told the outlet.

Medicare for All is the signature plan of Sen. Bernie Sanders, a leading Democratic presidential candidate that Ocasio-Cortez has thrown her support behind. It would provide comprehensive health coverage and do away with deductibles, premiums, and other out-of-pocket spending. Private insurance would be eliminated as well.

As of Wednesday, the coronavirus has infected more than 94,000 people in at least 80 countries beyond China, its point of origin. The death toll from the respiratory disease it causes, COVID-19, has killed more than 3,200 people, mostly in China. There are at least 128 confirmed cases in the US.

Over the last week, concerns have mounted that the skyrocketing costs of healthcare could form a barrier discouraging people from getting tested and receiving treatment for the virus.

Business Insider recently analyzed the medical bill of a Miami resident who tested negative for the coronavirus but still racked up a $1,400 in costs, though he was insured. The majority of it came from an emergency room visit.

The Trump administration announced on Monday it was reviewing what products and services it would cover for coronavirus under Medicare and Medicaid, the two biggest federal health insurance programs.

Vice President Mike Pence said a day later the programs would insure diagnostic testing, making it free for patients. But it was not immediately clear what additional medical care would be paid for by the government.

“People who are subject to cost sharing — they are less likely to use medical care, even if they need it,” John Cogan, a health-law expert at the University of Connecticut, previously told Business Insider.

The White House is also reportedly considering reimbursing hospitals and doctors for treating uninsured coronavirus patients. In 2018, 27.5 million Americans had no health insurance, an increase from 25.2 million the year before.

The Most Common Coronavirus Symptoms to Look Out for, According to Experts Coronavirus symptoms are similar to those associated with the flu. 

Unless you get a lab test, you can’t really distinguish between coronavirus COVID-19 and a typical cold or the flu. Dr. Wesley Long, Houston Methodist Director of Diagnostic Microbiology The severity of coronavirus

symptoms varies from person to person, Dr. Long notes. In more serious cases, the infection may lead to pneumonia, severe acute

respiratory syndrome, kidney failure, and even death, says Dr. Neal Shipley. Those most at risk of severe illness from coronavirus include the very young, the very old, and people with generally weakened or impaired immune systems. It’s difficult to pinpoint how long it takes

for coronavirus symptoms to appear. “The generally accepted window from exposure to onset of symptoms is 2-14 days,” says Dr. Long. To be clear, there’s still a lot that experts don’t know about COVID-19. And, you can only contract it if you’ve come into contact with someone who already has it.

So, rather than cause continual promotion of more fear we should all be prepared using good hand washing, cleaning surfaces with appropriate products, if you are sick seek assistance with your medical physician or nurse practitioner offices regarding the need to be tested, etc. The question looms out there, not if you will become sick with this virus, but when and how you care for yourself!

Stay well!!

What the Trump budget says about the administration’s health priorities; The Dems and Bloomberg and More on the Corona Virus

As Michael Bloomberg continues to attempt to buy the Primaries and the Elections let us look at Trump’s new budget and its effect on health care. University of Pennsylvania Assistant Professor of Public Policy, Simon F. Haeder reported that the Trump administration recently released its budget blueprint for the 2021 fiscal year, the first steps in the complex budgetary process.

The final budget will reflect the input of Congress, including the Democratic House of Representatives, and will look significantly different.

However, budget drafts by presidential administrations are not meaningless pages of paper. They are important policy documents highlighting goals, priorities and visions for the future of the country.

As a health care expert, I find the vision brought forward by the Trump administration deeply concerning. Cuts to virtually all important health-related programs bode ill for nations future. To make things worse, ancillary programs that are crucial for good health are also on the chopping block. To be sure, most of the proposed damage will find it hard to pass muster with Congress. Yet given the nation’s ever-growing debt Congress may soon be amenable to rolling back the nation’s health safety net.

Rolling back the ACA and the safety net

To no one’s surprise, some of the biggest cuts in the proposed budget focus on health care programs. The budget document uses a number of terms to disguise its true intentions. Yet a closer look indicates that terms like “rightsizing government,” “advancing the President’s health reform vision,” “modernizing Medicaid and the Children’s Health Insurance Program,” and “reforming welfare programs” all come down to the same end result: cuts to the safety net.

One of the main targets remains the Affordable Care Act, or ACA. In 2017, after several failed attempts to repeal and replace the ACA, the Trump administration has scaled back its open hostility. Instead of asking directly to repeal the ACA, this year’s budget proposal calls for initiatives to “advance the president’s health reform vision,” by cutting more than half a trillion dollars from the budget.

These initiatives come on top of actions the Trump administration has already taken to roll back the Affordable Care Act, including the repeal of the individual mandate penalty, severely limiting outreach and enrollment efforts, and creating a parallel insurance market by expanding the roles of short-term, limited duration and association health plans.

The Trump administration has also targeted Medicaid, the nation’s largest safety net program serving mostly low-income Americans, pregnant women, children, the disabled and those in need of long-term care, as well as its cousin, the Children’s Health Insurance Program. Overall “modernization” for these two programs alone would entail cuts of almost US$200 billion.

Medicare, the program serving America’s seniors, technically would not undergo significant restructuring. However, “streamlining” and “eliminating waste” would reduce the program by more than half a trillion dollars or 6%. All put together, cuts to the ACA, Medicaid and Medicare will exceed a trillion dollars over a decade. Coverage losses, mostly affecting lower-income Americans, would range in the millions of dollars.

Health is more than just medical care

In the U.S, we often equate health with access to medical care. However, researchers have long recognized that medical care contributes only about 10% to 20% to the health of individuals.

One crucial component of good health is access to education. However, the Trump budget includes cuts of more than $300 billion across the entire education spectrum from Head Start to grants that support college education. This just doesn’t make any sense!

Access to food and nutrition also plays a major role in maintaining good health. However, two programs providing important food security to millions of Americans would face significant cuts. For one, the Supplemental Nutrition Assistance Program (SNAP), which supplements food budgets for 34 million Americans with an annual budget of $58 billion, is slated for $22 billion in cuts over a decade. There are also cuts exceeding $2 billion over a decade to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which reaches more than 6 million Americans with an annual budget of $6.4 billion.

Cuts to nutritional benefits would be further compounded by a 15.2% reduction to the Department of Housing and Urban Development. The department provides a range of housing assistance programs to needy individuals. Moreover, the Temporary Assistance for Needy Families (TANF) program which provides cash benefits to needy families, faces 10% in cuts. Again, this doesn’t make any sense!

A healthy environment and access to clean air and water unquestionably are crucial to living a healthy life. However, the proposed budget would trim spending on the agency tasked with protecting the nation’s environment, the Environmental Protection Agency, by more than 40%, or $36 billion.

A myriad of public health crises has been slowly but steadily harming communities all across the country. Much of the attention has been garnered by the devastating opioid crisis. More recently, the coronavirus and the seasonal flu epidemic have caught the headlines. Yet, there are countless other epidemics harming communities around the country including syphilis, hepatitis C and gonorrhea. Yet the nation’s major public health agency, the Centers for Disease Control, would see its budget decline by 9%.

The Trump administration is also proposing to significantly reduce funding for health-related research programs. One target is the National Science Foundation, which would see a reduction by 6.5%. Moreover, the National Institutes of Health, the nation’s premier medical research agency, is set for 7.2% in cuts. Both agencies play crucial roles in positioning the nation to tackle current and future health challenges. Do any of these budget cuts make any sense?

A blueprint for the future?

Since the Kennedy administration, taxes have generally been cut and only rarely increased. Particularly large tax cuts under the George W. Bush administration, without commensurate budget cuts, have created a systemic imbalance in the federal budget. This imbalance was further exacerbated by the recent tax cuts under the Trump administration.

So far, we have been able to stall the eventual reckoning because of strong economic growth and our ability to borrow heavily. Eventually, it seems inevitable that this massive imbalance will catch up with us.

Faced with the choice to either raise taxes or cut programs, Congress may choose the latter. With defense spending largely untouchable, health programs and other social support systems will likely bear the brunt.

Democrats Get Personal on Healthcare 

Shannon Firth reported that the Democratic presidential candidates engaged in one of the most brutal and bruising fights to date, attacking each other’s integrity and physical fitness while still reserving time to tear into each other’s healthcare plans.

The debate took place in Las Vegas, with caucuses in Nevada only a few days away, and was broadcast by NBC/MSNBC.

Ahead of the debate, Sen. Bernie Sanders of Vermont, was leading nearly every poll according to RealClearPolitics.

In addition to Sanders, participants included former New York City Mayor Mike Bloomberg, Sen. Elizabeth Warren of Massachusetts, former Vice President Joe Biden, former South Bend, Indiana, Mayor Pete Buttigieg, and Sen. Amy Klobuchar of Minnesota.

Sanders’ health came under scrutiny in the wake of his October 2019 heart attack and stent placements.

When asked whether he would offer voters “full transparency” around his medical records, he was quick to point out that Bloomberg also has two stents. Sanders then said he had released the “full report” of his heart attack and decades of records from the attending physicians on Capitol Hill. (Last month, though, cardiologist Anthony Pearson, MD, noted that the recent report didn’t include Sanders’ left ventricular ejection fraction, a key indicator of cardiac function.)

In addition, two “leading Vermont cardiologists” had also released reports stating that he is “more than able to deal with the stress and the vigor of being president of the United States,” Sanders said, challenging anyone who doubts his stamina to “follow me around the campaign trail.”

Buttigieg quipped that Sanders was in “fighting shape,” but continued to stress the need for transparency.

When President Obama was in office the standard, he was to release “the read out” after a physical. While President Trump lowered that bar, Buttigieg said it should be raised.

“I am certainly prepared to get a physical, put out the results,” he said, “and I think everybody here should be willing to do the same.”

‘A PowerPoint,’ a ‘Post-It,’ and a ‘Good Start’

When it came to healthcare reform plans, Warren took aim at each of the other candidates.

Buttigieg has a “slogan” dreamed up by consultants, she said. “It’s not a plan, it’s a PowerPoint,” referring to Buttigieg’s “Medicare for All Who Want It.”

Buttigieg’s plan, which includes a public option, would initially preserve the role of private insurers, but later serve as a “glide path to Medicare for All.”

She likened Klobuchar’s plan, which also involves a public option, to a “a Post-It Note, ‘Insert plan here,'” then she took aim at Sanders’ more comprehensive plan. Although she had endorsed it in the first debate, this time she called it merely “a good start” that leaves gaping holes in how it would be implemented.

As candidate’s hands shot, with each rebuke, signaling a request to defend themselves, Warren shared her own vision for healthcare reform.

“[W]e need as much help for as many people as quickly as possible and bring in as many supporters as we can. And if we don’t get it all the first time,” presumably here she’s referring to a complete transition to a single-payer system, “… take the win and come back into the fight and ask for more,” Warren said.

Medicare for All has been a particular point of contention in Nevada, where the powerful Culinary Workers Union has been vocal in opposing any plan that takes away its members’ negotiated healthcare coverage. (The union declined to endorse any candidates in the state’s caucuses.) Asked about it in Wednesday’s debate, Sanders said, “I will never sign a bill that will reduce the healthcare benefits that they have, we will only expand it for them, for every union in America and for the working class of this country.”

Buttigieg, however, suggested that Sanders hadn’t been listening. “This idea that the union members don’t know what’s good for them is the exact kind of condescension and arrogance that makes people skeptical of the policies we’ve been putting forward.”

At another point, Biden took a shot at Bloomberg for having attacked the Affordable Care Act during a 2010 speech.

Bloomberg countered that he was in fact “a fan” of the landmark law. “I was in favor of it, I thought it didn’t… go as far as we should,” he said.

Now, his position is that Obamacare should be preserved and strengthened. “We shouldn’t just walk away and start something that is totally new, untried. People depend on this,” he said. One of his first moves as president would be to “bring back those things” that President Trump eliminated.

Other features of Bloomberg’s plan include a public option, caps on healthcare prices, and elimination of “surprise medical bills.” The overall goal is to achieve universal coverage while preserving private insurance.

Bloomberg To Grieving Family: Elderly Cancer Patients Are Too Expensive

Peter Hasson of the National Interest reported that Billionaire and Democratic presidential candidate Michael Bloomberg said in a 2011 video that elderly cancer patients should be denied treatment in order to cut health care costs.

“All of these costs keep going up, nobody wants to pay any more money, and at the rate we’re going, health care is going to bankrupt us,” said Bloomberg, who was then New York City’s mayor.

“We’ve got to sit here and say which things we’re going to do, and which things we’re not, nobody wants to do that. Y’know, if you show up with prostate cancer, you’re 95 years old, we should say, ‘Go and enjoy. Have a nice [inaudible]. Live a long life. There’s no cure, and we can’t do anything.’ If you’re a young person, we should do something about it,” Bloomberg said in the video.

“Society’s not ready to do that yet,” he added.

Bloomberg made the comments while visiting a grieving family whose brother had died after reportedly waiting 73 hours in an emergency room.

His presidential campaign didn’t return a request for comment.

The New York billionaire has faced increased scrutiny over past statements as he has continued to rise in Democratic primary polls.

Fake Facts Are Flying About Coronavirus. Now There’s A Plan to Debunk Them

We have been hearing all sorts of information regarding the Corona Virus and I thought that I would share some of the Fake Facts and some of the truths. Malaka Gharib reported that the coronavirus outbreak has sparked what the World Health Organization is calling an “infodemic” — an overwhelming amount of information on social media and websites. Some of it’s accurate. And some is downright untrue.

The false statements range from a conspiracy theory that the virus is a man-made bioweapon to the claim that more than 100,000 have died from the disease (as of this week, the number of reported fatalities is reported at 2,200-plus).

WHO is fighting back? In early January, a few weeks after China reported the first cases, the U.N. agency launched a pilot program to make sure the facts about the newly identified virus are communicated to the public. The project is called EPI-WIN — short for WHO Information Network for Epidemics.

“We need a vaccine against misinformation,” said Dr. Mike Ryan, head of WHO’s health emergencies program, at a WHO briefing on the virus earlier this month.

The Coronavirus Outbreak
What you should know

  • Where the virus has spread
  • Coronavirus 101
  • Coronavirus FAQs

While this is not the first health crisis that has been characterized by online misinformation — it happened with Ebola, for example — researchers are especially concerned because this outbreak is centered in China. The world’s most populous country has the largest market of Internet users globally: 21% of the world’s 3.8 billion Internet users are in China.

And fake news can spread quickly online. A 2018 study from Massachusetts Institute of Technology found that “false news spreads more rapidly on the social network Twitter than real news does.” The reason, say the researchers, may be that the untrue statements inspire strong feelings such as fear, disgust and surprise.

This dynamic could cause fake coronavirus cures and treatments to fan out widely on social media — and as a result, worsen the impact of the outbreak, says Bhaskar Chakravorti, dean of global business at the Fletcher School at Tufts University. Over the past decade, he has been tracking the effect of digital technology on issues such as global health and economic development.

The rumors offer remedies that have no basis in science. One untrue statement suggests that rubbing sesame oil on the skin will block the coronavirus.

If segments of the public turn to false treatments rather than follow the advice of trusted sources for avoiding illness (like frequent hand-washing with soap and water), it could cause “the disease to travel further and faster than it ordinarily would have,” says Chakravorti.

There could be a political agenda behind the fake coronavirus news as well. Countries that are antagonistic toward China could try to hijack the conversation in hopes of creating chaos and eroding trust in the authorities, says Dr. Margaret Bourdeaux, research director for Harvard Belfer Center’s Security and Global Health Project.

“Disinformation that specifically targets your health system or your leaders who are trying to manage an emergency is a way of destroying, undermining, disrupting your health system,” she says.

In the instance of vaccines, Russian bots have been identified as fueling skepticism about the effectiveness of vaccination for childhood diseases in the U.S.

The World Health Organization’s EPI-WIN team believes that the countermeasure for misinformation and disinformation is simply to tell the truth.

It works rapidly to debunk unjustified medical claims on social media. In a series of bright blue graphics posted on Instagram, EPI-WIN states categorically that neither sesame oil nor breathing in the smoke of fire or fireworks will kill the new coronavirus.

Part of this truth-telling strategy involves enlisting large-scale employers.

The approach, says Melinda Frost, an officer on the EPI-WIN team, is based on the idea that employers are the most trusted institution in society, a finding reflected in a 2020 study on global trust from the public relations firm Edelman: “People tend to trust their employers more than they trust several other sources of information.”

Over the past few weeks, Frost and her team have been organizing rounds of conference calls with representatives from Fortune 500 companies and other multinational corporations in sectors such as health, travel and tourism, food and agriculture, and business.

The company representatives share questions that their employees might have about the coronavirus outbreak — for example, is it safe to go to conferences? The EPI-WIN team gathers the frequently asked questions, has their experts answer them within a few days, and then sends the responses back to the companies to distribute in internal newsletters and other communication.

Because the information is coming from their employer, says Frost, the hope is that people will be more likely to believe what they hear and pass the information on to their family and community.

Bourdeaux at Harvard calls this approach a “smart move.”

It borrows from “advertising techniques from the 1950s,” she adds. “They’re establishing the narrative before anybody else can. They are going on offense, saying, ‘Here are the facts.’ “

WHO is also collaborating with tech giants like Google, Twitter, Facebook, Pinterest and TikTok to limit the spread of harmful rumors? It’s pursuing a similar tactic with Chinese digital companies such as Baidu, Tencent and Weibo.

“We are asking them to filter out false information and promote accurate information from credible sources like WHO, CDC [the U.S. Centers for Disease Control and Prevention] and others. And we thank them for their efforts so far,” said Dr. Tedros Adhanom Ghebreyesus, director-general of WHO, in a briefing earlier this month.

Google and Twitter, for example, now actively bump up credible sources such as WHO and the CDC in search results for the term “coronavirus.” And Facebook has deployed fact-checkers to remove content with false claims or conspiracy theories about the outbreak. Kang-Xing Jin, head of health at Facebook, wrote in a statement about one such rumor that it has eliminated from its platform: that drinking bleach cures coronavirus.

Chakravorti applauds WHO’s coordination with the digital companies — but says he’s particularly impressed with Facebook’s efforts. “This is a radical departure from Facebook’s past record, including its controversial insistence on permitting false political ads,” he wrote in an op-ed in Bloomberg News.

[Facebook and Twitter did not respond to requests from NPR for comments. Facebook is one of NPR’s financial sponsors.]

Still, there is no silver bullet to fighting health misinformation. It has become “very, very difficult to fight effectively,” says Chakravorti of Tufts University.

A post making a false claim about coronavirus can just “jump platforms,” he says. “So you might have Facebook taking down a post, but then the post finds its way on Twitter, then it jumps from Twitter to YouTube.”

In addition to efforts by WHO and other organizations, individuals are doing their part.

On Wednesday, The Lancet published a statement from 27 public health scientists addressing rumors that the coronavirus had been engineered in a Wuhan lab: “We stand together to strongly condemn conspiracy theories suggesting that COVID-19 does not have a natural origin …. Conspiracy theories do nothing but create fear, rumors and prejudice that jeopardize our global collaboration in the fight against this virus.”

Dr. Deliang Tang, a molecular epidemiologist at Columbia University’s Mailman School of Public Health, says his friends from medical school and his research colleagues in China find it difficult to trust Chinese health authorities, especially after police reprimanded the eight Chinese doctors who warned others about a pneumonialike disease in December.

As a result, Tang’s network in China has been looking to him and others in the scientific community to share information.

Since the outbreak began, Tang says he has been answering “30 to 50 questions a night.” Many want to fact-check rumors or learn about clinical trials for a potential cure.

“My real work starts at 7 p.m.,” he says — morning in China.

And the latest news on the Corona virus: Coronavirus update: 80,238 cases, 2,700 deaths; CDC warns Americans to prepare for disruption

And: Harvard scientist predicts coronavirus will infect up to 70 percent of humanity

More on the Corona Virus next week!

Red and Blue America see eye-to-eye on one issue: the nation’s health care system needs fixing and What is Missing in Medicare for All and What is Stressing Us All?

USA TODAY’s Jayne O’Donnell noted that Health care is one of the most divisive issues of the 2020 presidential campaign, with candidates disparaging insurers and polarizing labels creating deep divisions even among Democrats. But remove the buzzwords from the policies, and voters who will decide the election aren’t so far apart in their own positions, new research shows. But remember what I have been questioning for the last at least 6 months- with all the concern why hasn’t neither the Republicans nor the Democrats have done anything when they had control, i.e. had the majorities in the House or the Senate? And will Mike Bloomberg come to the Democrats’ recur and solve everyones’ problems?

Regardless of party affiliation, nearly everyone wants to see the nation’s health care system improved, and a majority want big changes. That includes people for whom the system is working well, and those who may be political opposites. 

That’s the big picture finding of a new Public Agenda/USA TODAY/Ipsos survey of Americans’ attitudes on health care. The survey is part of the Hidden Common Ground 2020 Initiative, which seeks to explore areas of agreement on major issues facing the nation.

The nationally representative survey of 1,020 adult Americans 18 years and older was conducted December 19-26, 2019. It has a margin of error of plus or minus 3.3 percentage points. 

The survey removed politically charged language such as “Medicare for All” and “Obamacare” and simply explained the basics of health care approaches in an effort to capture voters’ true opinions. 

“There’s the making of a public conversation about this and it does not need to be around ideology,” said Will Friedman, president of Public Agenda, a nonpartisan, nonprofit research and public engagement organization. “People just aren’t so set on what they want.”

The sharpest divides were on the size of government and taxes. 

In general, Democrats were more comfortable with a larger role for the federal government, such as the single-payer government insurance program also called Medicare for All, or a public option.

Instead of saying “public option” though, pollsters asked respondents how strongly they agreed with the concept of a new federal health insurance program that gives people a new choice beyond the current private insurance market.

Any adult could buy into the program on a sliding scale, they were told, and 48% were in favor. A survey released last week by the nonpartisan Kaiser Family Foundation found similar support, with the same percentage of Americans favoring such an option.

When described in general terms, 46% of respondents said they would support market-based plans and 45% could back Medicare for All-type plans.  

Five goals were rated by more than 90% of those surveyedas very or somewhat important: making health care more affordable for ordinary Americans; lowering the cost of prescription drugs; making sure people with preexisting medical conditions can get affordable health insurance; covering long-term care for the elderly and disabled; and making sure all communities have access to enough doctors and hospitals.

So why the gridlock?

“There are these sort of flashpoints with politicized terminology that send people to their partisan corners,” said former Vermont Gov. Jim Douglas, a Republican who is on the board of the bipartisan, nonprofit United States of Care. “If we avoid them, we’re going to be more successful.”

John Greifzu, a survey respondent and school janitor in Fulton, Illinois, used to be a Democrat and “almost middle of the road.” Now, after being a single father of three children until his recent marriage, health insurance costs have made him distrust his party.

His wife is “paying an arm and a leg” — up to a third of a paycheck — for “bottom of the barrel” insurance that comes with a $2,000 deductible through her retail job. And even on the Medicaid plans that cover his children, there are things that aren’t covered, he said.

Greifzu watched his insurance costs rise as it became offered to the unemployed. 

“I work hard for what I’ve got,” said Greifzu. “I’m not going to give up more money for people who don’t do anything.” 

Emily Barson, United States of Care’s executive director, said the survey “validates our worldview … that people agree more than the current political rhetoric would have you believe.” 

It also shows success at the state level is particularly promising, Barson added.

Before the midterm congressional elections, some Republican members of Congress avoided unscripted town halls with voters as concerns rose about the fate of the Affordable Care Act and protections for people with preexisting conditions. In states, Douglas said governors and state officials can’t avoid voters — or each other. 

State officials need to get elected too, but “more importantly, we (states) have to balance our budgets every year,” said Douglas, now a political science professor at Middlebury College.

Friedman noted, however, that voters made it clear in their responses that they don’t want policymakers to leave health care issues to the states. When queried on the specifics, respondents said they didn’t want moving from state to state to make health care any more complicated.  

“In terms of the overarching solution, the public would like to see it solved nationally,” he said. 

Larry Levitt, senior vice president at the Kaiser Family Foundation, said most of all it’s clear voters want something done about the prices they pay. 

“Americans across the political spectrum desperately want relief from health care costs,” Levitt said, “and at some point they’re going to hold political leaders to account for not delivering.”

Obamacare, Medicare and more 

The findings from the Public Agenda/USA TODAY/Ipsos poll are part of an election-year project by USA TODAY and Public Agenda. The Hidden Common Ground initiative explores areas of agreement on major issues facing the nation.

The survey of 1,020 adult Americans 18 years and older was taken December 19-26, 2019. It has a margin of error of plus or minus 5.7 percentage points for Democrats, plus or minus 6.2 percentage points for Republicans and plus or minus 5.7 percentage points for independents. 

The Hidden Common Ground project is supported by the John S. and James L. Knight Foundation, the Charles Koch Foundation and the Rockefeller Brothers Fund. The Kettering Foundation serves as a research partner to the Hidden Common Ground initiative.

Cost of health care, lack of data security stress us out. It’s time to claim our rights.

USA TODAY opinion contributor, Jane Sarasohn-Kahn reported that Americans are stressed out about health care.

Whether it concerns costs, access to treatment or ability to navigate the system, the American Psychological Association, in its 2019 Stress in America survey, found that 69% of people in the United States say health care is a major source of stress in their life.

We’re also stressed about privacy and data security. We live with a patchwork quilt of laws but no overarching protection that allows us to control our personal information.

As Americans, we need to demand our health citizenship. What does this mean? That people claim health care and data privacy as civil rights.

Polls show that most Americans, from top income earners to people living with much less, believe that it’s unfair for wealthier people to have access to better health care.

In an election year where there seems to be little consensus, two issues on which most American voters agree is the need to lower prescription drugs costs and to protect patients with preexisting conditions. These are priorities that cross party lines in 2020.

What’s driving this cross-party consensus? It’s the reality of patients spending increasingly higher amounts of household income on high-deductible health plans, medical services and prescription drugs. Forcing patients to have more financial “skin in the game” has led millions of Americans to forgo care altogether or to self-ration care by not getting recommended tests and not filling prescriptions.

The second driver for the declaration of health citizenship is the urgent need to protect our personal health information.

In 1996, when the Health Insurance Portability and Accountability Act was enacted, the introduction of the iPhone was 11 years away. The internet was dial up to AOL, CompuServe and Prodigy. And per-capita spending on health care averaged $3,759 (in 2018, it was $11,172).

Health care in 2020 is digitally based, with most physicians and hospitals in America using electronic health records and providers conducting care online via web-based services. Health care is quickly moving to the home, to our cars and even inside our bodies with implants. Wearable technology, remote health monitoring and mobile apps increasingly support our self-care and shared-care with clinicians.

Our health data is vulnerable

Those interactions create new data points. So do daily interactions with our phones and retail purchases. That information, when mashed up with our health care data, can be used to predict our health status, identify emergent conditions like a heart attack or stroke, and customize medications for patients.

But the data generated by our daily lives, outside of HIPAA-covered entities such as doctors, hospitals and pharmacies, is not for the most part covered by existing laws. We are exposed to third-party brokers who monetize our data without telling us how it’s used and without sharing the revenue they make from our personal information.

Universal care is basic right

What would a new era of health citizenship look like? Every American would be covered by a health plan — however we fashion it.

Universal health care, American-style, could come in many forms, including through proposals under debate during the election cycle. All residents in our peer nations in the Organization for Economic Cooperation and Development enjoy some form of health care plan. Most of these countries spend less on health care per person and realize better health outcomes.

One reason is that those nations spend more per person on social factors that help determine a person’s health.

Education, for example, is a major predictor of people’s health. Sir Angus Deaton and Anne Case’s research into the “deaths of despair” in America identified lack of education as a risk factor. Lawmakers need to “bake” health into food and agriculture, transportation, housing and education policies to improve the health of all Americans regardless of income or education levels.

We also need to help people understand the growing role of data in everyday life. Virtually everyone leaves digital dust in the use of mobile phones, credit cards and online transactions. Our peers in Europe enjoy the privacy protection afforded by the General Data Protection Regulation, which defends the “right to be forgotten.” In the United States, we lack laws that sufficiently protect our personal data.

Voting is part of health citizenship, too. The Stress in America survey cited the 2020 presidential election as a major source of Americans’ stress. Let’s make the act of voting a part of our pursuit of good health’

Medicare for All is really missing the point: Experts say program needs work

Ken Alltucker of USA TODAY, reported that when Robert Davis’ prescription medication money ran out weeks ago, he began rationing a life-sustaining $292,000-per-year drug he takes to treat his cystic fibrosis.

Tuesday, the suburban Houston man and father of two got a lifeline in the mail: a free 30-day supply of a newer, even more expensive triple-combination drug with an annual cost of $311,000.

The drug will bring him relief over the next month, but he’s uncertain what will happen next. Although the 50-year-old has Medicare prescription drug coverage, he can’t afford copays for it or other drugs he must take to stay healthy as he battles the life-shortening lung disorder. 

Davis is among millions of Americans with chronic disease who struggle to pay medical bills even with robust Medicare benefits. More than one in three Medicare recipients with a serious illness say they spend all of their savings to pay for health care. And nearly one in four have been pressured by bill collectors, according to a study supported by the Commonwealth Fund.

As Democratic presidential candidates Elizabeth Warren, Bernie Sanders and others tout “Medicare for All” to change the nation’s expensive and inequitable health care system, some advocates warn the Medicare program is far from perfect for the elderly and disabled enrolled in it. 

The word “Medicare” was mentioned 17 times during Wednesday night’s debate in the context of a national health plan or a public option people could purchase. However, there’s been little to no discussion among the candidates in debates about the actual status of the health program that covers about 60 million Americans.Ad

One in two Democrats and Democrat-leaning independents want to hear more about how candidates’ plans would affect seniors on Medicare, making it the top health-related concern they’d like candidates to discuss, according to a Kaiser Family Foundation poll released Wednesday. 

“We fear the debate about ‘Medicare for All’ is really missing the point,” says Judith Stein, director of the Center for Medicare Advocacy. “What most people don’t know is the current Medicare program has a lot of problems with it. We need to improve Medicare before it becomes a vehicle for a broad group of people.”

Medicare for All faces broad political challenges. About 53% support a national Medicare for All plan, but that support drops below 50% with more details about paying taxes to support a single-payer system, according to the Kaiser poll.

Nearly two in three moderate voters in Michigan, Minnesota, Pennsylvania and Wisconsin are skeptical of a plan to use Medicare as a vehicle for comprehensive health coverage, another Kaiser and Cook Political Report poll released this month shows. A group funded by pharmaceutical companies, health insurers and hospitals has lobbied against Medicare for All, and a survey released by HealthSavings Administrators reported participating employers oppose the plan.

This month, Warren released more details about her health plan, calling for a public option within the first 100 days of her presidency. She said it was not a retreat from Medicare for All, even as a Des Moines Register/CNN/Mediacom Iowa Poll showed her support in Iowa dropped to 16%.

Stephen Zuckerman is a health economist and co-director of the Urban Institute Health Policy Center. He says the Medicare for All proposals expand coverage beyond what Medicare beneficiaries get.

“If you hear about Medicare for All, you might think it’s the current Medicare program for all people,” Zuckerman said. “But that’s not what the Medicare for All proposals are presenting. They are looking at plans that are far more generous, in terms of the benefits they cover and to some extent the cost sharing.”

The fundamental promise of Medicare for All builds on a public program that works well for adults over 65 and people who are unable to work because of disability. Although Medicare rates high in satisfaction among most who have it, a portion of people who need frequent, expensive care struggle financially.

The Commonwealth Fund-supported survey of 742 Medicare beneficiaries reported 53% of those with “serious illness” had a problem paying a medical bill. The study defined serious illness as one requiring two or more hospital stays and three or more doctor visits over three years.

Among these seriously ill patients, the most common financial hardship involved medication. Nearly one in three people reported a serious problem paying for prescriptions. People had problems paying hospital, ambulance and emergency room bills, according to the survey.

Eric Schneider, a Commonwealth Fund senior vice president for policy and research, says the survey’s findings show seriously ill Medicare recipients face “significant financial exposure.

“The expectation is that people would be relatively well-covered under Medicare,” Schneider says. “We’re seeing it has gaps and holes, particularly considering the level of poverty many elderly still live in.”

‘More illness, more sickness’

Davis, the Houston-area man, has rationed expensive but critical modulator drugs, which seek to improve lung function by targeting defects caused by genetic mutations. 

When he ran out of the drug Symdeko last November, he coughed up blood, had digestive problems and was hospitalized for a week. This month, he took half the amount he was prescribed, hoping he’d have enough pills to last through the year.  

“It alters my breathing a lot,” Davis says. “I’m more congested. I start slowing down, more illness, more sickness.”

Davis has Medicare prescription coverage, but he couldn’t afford Symdeko’s $1,200 monthly copay. He needs to pay an additional $600 each month for a less expensive drug, pulmozyme, which breaks down and clears mucus from his lungs. The medication he takes is critical to keep his lungs functioning and to limit infections. 

A private foundation offers copay assistance up to $15,000 each year, a threshold Davis reached this month. Like a year ago, as rent, food and utility bills took most of his disability income, the math didn’t work. He could no longer afford drugs when the foundation’s annual help ran out.

A 30-day supply of the newer drug, Trikafta, was provided by the drug’s manufacturer free of charge. Davis worries he will run into the same problem when he’s again forced to cover a copay he can’t afford.

His Medicare coverage is sufficient for doctor visits and hospital stays, but he says drug costs for cystic fibrosis patients are “out of control.” 

“Research is expensive – I understand that,” Davis says. “They are making lifesaving drugs that very few cystic fibrosis patients can afford and that a lot of insurance plans will balk at.”

Vertex Pharmaceuticals, the company that makes Symdeko and Trikafta, says the drugs’ list prices are appropriate.

“Our CF medicines are the first and only medicines to treat the underlying cause of this devastating disease and the price of our medicines reflect the significant value they bring to patients,” the company says in a statement. 

Vertex provides financial assistance to patients such as Davis who need the company’s medications. 

“Our highest priority is making sure patients who need our medicines can get them,” the company says. “Every patient situation is different, and our (patient-assistance) team works individually with patients who are enrolled in the program to evaluate their specific situations and determine what assistance options are available.” 

‘Public Medicare plan is withering’

Advocates such as Stein want presidential candidates to address Medicare’s coverage gaps and other challenges mill

ions of beneficiaries face.

The Commonwealth Fund survey did not report whether participants had traditional Medicare plans or Medicare Advantage plans, which are administered by private insurance companies such as Aetna or UnitedHealthcare. The report did not ask participants whether they had supplemental insurance, which covers out-of-pocket medical expenses not capped by Medicare. 

People on Medicare typically have robust coverage for hospital stays and doctor charges. But even with “Part D” prescription drug coverage, Davis and others who must take expensive drugs are responsible for copays.

“What is happening is the public Medicare program is withering,” Stein says. “The private, more expensive, less valuable Medicare Advantage program is being pumped up.”

More than one-third of Americans choose private Medicare plans, which entice consumers through add-on services such as vision and dental coverage and perks such as gym memberships. A survey commissioned by the Better Medicare Alliance, which is backed by the private insurance industry, reported 94% of people in private Medicare plans are satisfied with their coverage.

Private Medicare plans restrict the network of available doctors, hospitals and specialists people can see. Traditional Medicare plans allow people to see any doctor or hospital that takes Medicare.

Stein says tailored networks can be problematic for seniors who travel out of state and encounter a medical emergency.

She says private plans frequently change doctors and hospital networks from year to year. Such frequent network changes can surprise Medicare recipients and force them to switch doctors.

“There’s too much confusion, too little standardization,” Stein says. “The inability, when you are really ill or injured, to get the care where you want it and from whom you want it, I think that is completely lost in the discussion.”

This month, President Donald Trump signed an executive order “protecting and improving” Medicare, but some worry it could push more consumers into private plans and lead to more expensive medical bills. Among other things, the order calls for Medicare to pay rates closer to those paid by private insurers. Medicare typically pays doctors less than what private commercial plans pay.

The federal rules based on the executive order haven’t been finalized, so it’s unclear how it might be implemented. 

The executive order “doesn’t seem all that well thought out,” Zuckerman says. Raising Medicare’s payment rates to be on par with private insurance would make the program more expensive and potentially financially vulnerable, he says.

“Public opinion wants to see that program preserved,” Zuckerman says. “At a minimum, I don’t think anyone wants to see Medicare contract.”

US health care system causing ‘moral injury’ among doctors, nurses

Megan Henney of FOX Business noted that the emphasis on speed and money — rather than patient care — in emergency medicine is leading to mass exasperation and burnout among clinicians across the country.

According to a new report published by Kaiser Health News, a model of emergency care is forcing doctors to practice “fast and loose medicine,” including excessive testing that leaves patients burdened with hefty medical bills; prioritizing speed at the cost of quality care and overcrowding in hospitals, among other issues.

“The health system is not set up to help patients,” Dr. Nick Sawyer, an assistant professor of emergency medicine at the University of California-Davis, told Kaiser Health. “It’s set up to make money.”

In October, a 312-page report published by the National Academy of Medicine, a non-profit organization based in Washington, D.C., found that up to half of all clinicians have reported “substantial” feelings of burnout, including exhaustion, high depersonalization and a low sense of personal accomplishment.

Physician burnout can result in increased risk to patients, malpractice claims, clinician absenteeism, high employee turnover and overall reduced productivity. In addition to posing a threat to the safety of patients and physicians, burnout carries a hefty economic cost: A previous study published in June by the Annals of Internal Medicine estimated that physician burnout costs the U.S. economy roughly $4.6 billion per year, or $7,600 per physician per year.

Physicians suffering from burnout are at least twice as likely to report that they’ve made a major medical error in the last three months, compared to their colleagues, and they’re also more likely to be involved in a malpractice litigation suit, the report found. Each year, about 2,400 physicians leave the workforce — and the No. 1 factor is burnout.

The authors of the report, who spent 18 months studying research on burnout, found that between 35 and 54 percent of nurses and doctors experience burnout. Among medical students and residents, the percentage is as high as 60 percent.

“There is a serious problem of burnout among health care professionals in this country, with consequences for both clinicians and patients, health care organizations and society,” the report said.

But the issue in emergency medicine goes beyond burnout. A 2018 report published by Drs. Wendy Dean and Simon Talbot found that physicians are facing a “profound and unrecognized threat” to their well-being: moral injury.

The term “moral injury” was first used to describe soldiers’ response to war and is frequently diagnosed as post-traumatic stress. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”

At the crux of moral injury in physicians is their inability to consistently meet patient’s needs, a symptom of a health-care environment that’s increasingly focused on maximizing profit that leaves clinicians trapped between navigating an ethical path or “making a profit from people at their sickest and most vulnerable.”

“The moral injury of health care is not the offense of killing another human in the context of war,” Dean and Talbot wrote. “It is being unable to provide high-quality care and healing in the context of health care.”

In the one year since they published their paper, Dean and Talbot sparked an international conversation among health care professionals about the moral foundations of medicine, receiving a flood of responses.

“All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do,” they wrote. “But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict.”

And as I am watching the New Hampshire Primary results I am amazed that Bernie is heading the Dems, as they are saying, based on his push for Medicare for All. Just a flawed proposal and evidently there are many that believe this Socialist. I am truly worried.

More Patients Insured in U.S. and More Can’t Afford Doctors but May-be Americans Don’t Really Want Medicare for All — They Want Japa-nese Health Care and the American College of Physicians

As the Democrat presidential candidates argue about Medicare for All as well as alternate programs I still wonder if Americans really know what they want for a health care plan at all. Rapport of Reuters Health noted that A growing number of Americans find it too expensive to see doctors even though more people have health insurance, a U.S. study suggests. But just wait Bernie Sanders is going to give us all free health care, free education, free everything, which the big businesses will pay for. Really?

Over the past two decades, the proportion of adults without insurance dropped to 14.8% from 16.9%, the study found. But during this same period, the proportion of adults unable to afford doctor visits climbed from 11.4% to 15.7%.

Out-of-pocket costs made doctors too expensive for the uninsured, but costs also kept people with coverage from seeing physicians even when they had chronic medical conditions requiring regular checkups.

“The quality of private health insurance is getting worse, and the cost of healthcare is rising significantly,” said lead study author Dr. Laura Hawks of the Cambridge Health Alliance and Harvard Medical School in Boston.

“We know that private health insurance plans increasing rely on high premiums, high-deductible health plans . . . high copays and other forms of cost-sharing,” Hawks said by email. “All these create financial barriers.”

For the study, researchers examined survey data collected from 1998 to 2017 by the Centers for Disease Control and Prevention. They wanted to see how access to care changed after the Affordable Care Act (ACA) was implemented 2014.

The proportion of adults 18 to 64 years old who couldn’t afford to see a doctor climbed slowly from 1998 to 2009, then rose more rapidly for several years before improving with the passage of the ACA, researchers report in JAMA Internal Medicine. But even after the ACA took effect, the proportion of adults able to afford checkups never returned to 1998 levels.

Affordability worsened across all racial and ethnic groups, and nearly all income groups, the study found.

Among the uninsured, the proportion of adults unable to afford physician visits climbed from 32.9% to 39.6% during the two-decade study period.

For people with health benefits, the proportion unable to pay for doctor visits rose from 7.1% to 11.5%.

The inability to see a doctor because of costs rose for people with many common chronic health problems including heart disease, high cholesterol and alcohol use disorders.

The study didn’t look at how shifts in the affordability of physician checkups might directly affect health outcomes.

One limitation of the analysis is that researchers lacked data on the affordability of prescription medications, which can also impact health as well as how often people need to see doctors.

“We knew that uninsured adults are much more likely than insured adults to avoid seeing a doctor due to cost, and uninsured adults with chronic conditions such as diabetes or heart disease are much less likely to get regular check-ups,” said Dr. John Ayanian, director of the Institute for Healthcare Policy and Innovation at the University of Michigan in Ann Arbor, who wrote an editorial accompanying the study.

Still, the results underscore that the ACA hasn’t insured everyone who needs coverage or made care affordable for all Americans, Ayanian said by email.

This means patients who struggle to pay for checkups need to ask for help.

“For people with chronic conditions such as diabetes, high blood pressure, or heart disease who have difficulty affording their ongoing care, I recommend they speak to their doctor and pharmacist about ways to save costs, including reduced fees for office visits or switching to less expensive generic medications,” Ayanian said. “Community health centers or hospital clinics may also have special programs to provide care for free or reduced fees for lower-income patients who are uninsured or who have high levels of medical debt.”

Japan provides a model for Americans who want a system that covers everyone with no mandate and no new middle-class taxes

Jon Wallker noted that Bernie Sanders has made a habit of pointing out how much less other countries pay for health care. Throughout the Democratic debates, the Vermont senator repeatedly claimed that the United States is “spending twice as much per capita on health care as any other nation.”

Sanders of course doesn’t mention that his plan wouldn’t come anywhere close to cutting our health care spending in half — doing so would require bringing salaries for doctors and hospital workers down to international norms. His omission is no surprise: Too often, American politicians rely on superficial comparisons with other nations to promote their health care agendas. Moderate Democrats often claim Obamacare should resemble the Swiss health care system, though in reality Obamacare lacked all the regulations that make that system function. Conservatives frequently try to scare people by pointing to highly selective stories of wait times in Canada or Britain, while ignoring the infinite wait time caused by not being able to afford care here.

If we look honestly at all the health care systems in the world to find the one which most closely aligns with voters’ desires, we would probably end up with the Japanese model. It is not the system anyone would design from scratch. It is a relatively complex system that evolved over decades to fit the needs, changing dynamics, and political trade-offs of the country. But for that very reason, it might most closely satisfy Americans’ seemingly endlessly contradicting opinions on reform.

Japan has more than 3,000 insurance plans, yet the benefit is not nearly the costly mess it is in the United States.

The Japanese health care system is based on employer- or union-provided insurance, just like the American one. People not covered by employer insurance are covered by government plans. Seniors basically have their own special coverage. The poor and disabled have special subsidies. Cumulatively, Japan has over 3,000 insurance plans, yet the benefit is not nearly the costly mess it is in the United States.

The thousands of plans in the U.S. individually negotiate with thousands of providers for millions of different prices. This drives up prices and creates massive administrative waste. In Japan, everything is highly standardized by the federal government. All plans need to cover the same set of benefits, reimburse providers the same amounts, use the same forms, and so on. Japanese employers can provide extra benefits on top of the standard baseline and what you pay depends partly on your employer’s risk pool, like in the U.S., but overall the difference between the plans is minor. As a result, Japan’s administrative spending is below that of many single-payer countries like Canada.

In practice, the Japanese system doesn’t seem much different than single-payer systems: In Japan, large companies set money aside in special accounts, and the government then tells them how to pay hospitals. In single-payer systems, large companies have to give money to a special government account, which then gives it to hospitals. However, the difference has real political implications.

Rhetorically, American politics is weirdly obsessed with people “losing their employer health insurance,” but we rarely ever talk about how insurance changes almost every year, usually for the worse: higher deductibles, new narrower networks, more co-pays, and so on. Only 44% of Americans say they would prefer a system mostly run by the government and 68% have a favorable view of employer coverage. Yet, at the same time, insurance regulations the government puts on employer coverage are very popular.

This employer coverage also solves the funding problem which plagues reform efforts. Americans don’t seem to understand or simply don’t care just how much they indirectly pay for employer insurance. The type of broad new taxes needed to pay for Medicare for All tend to be very unpopular. Even with very favorable wording, polling by YouGov found just 32% supported paying for Medicare for All with a tax on income over $29,000. (Proponents of M4A claim the net savings from no premiums or coinsurance would outweigh the cost of new taxes.) Even in deep blue Vermont, once local Democrats saw the size of the taxes needed to replace employer premiums — an 11.5% payroll tax and a new income tax of up to 9.5% — they declared their single-payer plan politically infeasible.

The same poll found a per-employee fee proposed by Sen. Elizabeth Warren to get around this anti-tax problem polls better, with 50% yes and 31% no. Yet what is consistently even more popular is just mandating all employers provide quality insurance, like Japan does. That polls at 69% support.

The Japanese model also provides a solution for Americans’ seemingly conflicting desires for a system that features no new middle-class taxes, no individual mandate, and yet covers everyone. In Japan, people without employer insurance need to buy coverage from their local government. Premiums are subsidized for those with lower incomes. If you don’t pay for insurance, though, there is no direct penalty, except when you do reenter the system you can be made to pay back premiums. Basically, if there is some small group of recalcitrants who want to try to avoid health insurance altogether, just let them and charge them when they do seek treatment.

There are two main ways Japan controls cost. The first is standardized cost-sharing. There are no deductibles, but people have a 30% coinsurance up to a monthly limit. There is no gatekeeping or preauthorization, but if you go to a specialist without a referral, you need to pay extra. Cost-sharing is one mechanism Americans have already come to accept for decades.

The other main tool is the that government aggressively sets low uniform prices with doctors, hospitals, and drug makers. This is why it works. This is also the part of the Japanese system which would generate the greatest industry opposition in the United States — as would Medicare for All for the same reasons. And even a decent Medicare buy-in would likely end up a de facto benchmark rate for providers.

All adopting a Japanese type of system would require is for the U.S. to take what it is currently doing and heavily standardize it. The biggest change would be scrapping the individual non-employer-based market to put everyone on a government plan, but the individual market is the least popular part of our system anyway. The majority of people with employer insurance would still have their same “private coverage,” with the same branding, but now cheaper and better. It would be the least disruptive system to copy, and it even has a precedent here. Hawaii has mandated every employer provide standardized, affordable, high-quality insurance since 1974, thanks to a special waiver from federal laws that prevent other states from copying Hawaii’s model.

The price of the lack of disruption, though, is not addressing many of the financing fairness issues we rarely talk about. Companies with younger workers would still pay less than companies with older workers. People living in high-cost localities would still pay higher premiums than people in low-cost areas. The overall funding would remain roughly as regressive as it currently is.

Polling shows even Democratic voters rank lowering drug prices, lowering what people pay, and ending surprise billing as bigger priorities than Medicare for All. And it is not clear people who claim they favor Medicare for All actually want the level of change it would cause. Polling shows 68% of Democrats incorrectly believe that under Medicare for All people would be allowed to keep their employer coverage, and 61% of Democrats believe the employers/individuals would continue to pay premiums, according to a poll this year by the Kaiser Family Foundation.

Meanwhile, moderate Democrats like Joe Biden are offering voters more layers of complexity instead of simple solutions. Instead of just directly mandating all employer coverage be as good and affordable as his proposed public option, Biden simply allows every worker to run the complicated cost calculations themselves to decide if their employer plan is a worse deal for them than the public option. While Japan automatically ensures your coverage is good, Biden makes that task a yearly burden for employees — which is deeply problematic since only 4% of Americans understand basic insurance terms.

It is possible adopting a Japanese-style health care system might even be the fastest way to Medicare for All. South Korea created universal health care via a system very similar to Japan in 1989 and then in 2000 decided to move to a true single-payer system. Of course “have the federal government set prices, heavily regulate employer insurance so it acts basically like Medicare, and making buying subsidized Medicare quasi-optional for everyone else,” isn’t the catchiest slogan. So, it is unlikely voters will ever hear about a path that could give them what they seem to want championed.

ACP Backs Single-Payer Healthcare

Alicia Ault noted that The American College of Physicians (ACP) is backing both a single-payer system and a public option that retains private insurance as the best ways to ensure that all Americans have healthcare.

The ACP’s endorsement comes as part of a broad proposal to overhaul the US healthcare system, published today in the Annals of Internal Medicine.

Rather than continue to react to others’ proposals, the ACP decided, “we are going to stick our necks out and put forward what we think is a better way,” Bob Doherty, ACP senior vice president for governmental affairs and public policy, told Medscape Medical News. 

It is a break from previous ACP policy — which never explicitly backed single payer — and with other physician organizations, including the American Medical Association and the American Academy of Family Physicians, both of which have declined to back a single-payer healthcare system.

The ACP’s board of regents endorsed the overhaul proposal in November, and Doherty said he was confident that it had the backing of the majority of the organization’s 159,000 internists and medical students.

Physicians for a National Health Program (PNHP) applauded the ACP’s policy shift.

“For a century, most US medical organizations opposed national health insurance,” PNHP cofounders Steffie Woolhandler, MD, and David Himmelstein, MD, write in an Annals editorial. “The endorsement by the American College of Physicians (ACP) of single-payer reform marks a sea change from this unfortunate tradition,” they say.

No Political Endorsement

The ACP timed its announcement to come just before the first major presidential primary contests in Iowa (February 3) and New Hampshire (February 11), but the organization is not backing any candidate’s healthcare proposal.

“We know that election years, particularly presidential election years, create an opportunity to engage in discussion about the future of public policy,” Doherty said, adding that healthcare, and in particular affordability, rank among voters’ top concerns.

After examining health systems in a dozen countries and reviewing policies that have been proposed for the United States, the ACP decided that both single payer and a public option would increase universal coverage, one of the ACP’s long-stated policy goals.

“For us to say single payer is the only way to achieve universal coverage is just not consistent with the evidence,” Doherty said. The coverage goal can also be achieved with a public option, “provided that you had enough marketplace regulation of private insurance that would be competing with the public program,” and if there was automatic enrollment for people who did not have private insurance, Doherty said.

Negotiate Payment Rates

Unlike Democratic presidential candidate Elizabeth Warren’s plan to pay for her Medicare for All plan by pegging physician and hospital pay to Medicare rates, the ACP said that would not work.  

“There would have to be a process to negotiate for established rates that would be sufficient to ensure that physicians would participate in the program,” Doherty said.

As part of its multipronged overhaul, the ACP is also proposing an elimination of copays and deductibles for high-value services such as primary care, and also for patients with chronic diseases.

A renewed emphasis on primary care would create savings, the ACP posited in its call to action and the four papers outlining its positions on how to overhaul the health system.

“We believe that American health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients’ interests; undervalues primary care and under invests in public health; spending too much on administration at the expense of patient care; and fosters barriers to care for and discrimination against vulnerable individuals,” said ACP President Robert M. McLean, MD, MACP, in a statement.

I believe that the ACP has some interesting reasonable solutions as well as my opinion that President Obama and his experts came up with a great plan except for financial sustainability. As a country we have to realize that any sustainable program will be costly and the cost will be shared by all. Do we all really want Bernie or Elizabeth to be our presidents to drive our country to the edge and convert to socialism? Wake up America!

My Millennial Doctor Peers Think They’re Walking Into a Crisis Regarding Health Care, Doctors Need to Understand Health Care and Buttagieg’s Health Care Plan, Corona Virus and Kobe.

Dr. Daniel E. Choi announced that ”Hey man, just wanted you to be one of the first to know that I put in my 90-day resignation notice at the hospital. Planning to pursue exec MBA…”

I did a double take at this shocking text from an orthopedic surgery colleague who was also a close friend. What? He was quitting?

We had just slaved through 5 years of orthopedic surgery residency, 1 year of fellowship, and just passed our oral boards. We were now supposed to be living the dream. All of that delayed gratification: throwing away our 20s holed up in the library, taking call endlessly on weekends and holidays. We did it for the ultimate privilege of being attending surgeons for our patients one day.

I called him right away and he confirmed my suspicions about why he quit. As an employed physician in a hospital system, he felt that he was sadly just becoming a cog in the machine, a “provider” generating relative value units. Administrators who had never done a day of residency or even stepped foot in his clinic wanted to provide “guidance” on how he should practice medicine. Overall, he felt that medicine was a sinking ship on which doctors were losing autonomy quickly and that this was a path leading straight to burnout.

I felt I had to let the Twitterverse know.

This tweet went viral and it was clear that I was on to something. I had struck a nerve with many of my physician colleagues. Surprisingly, many physicians empathized with my friend and didn’t blame him for looking elsewhere in finding a fulfilling career. Some physicians even thought he was doing the right thing.

I was getting really curious. I followed up with a Twitter poll: “Physicians, are you actively making plans for early retirement or considering how to possibly exit medicine in the near future?” Sixty-five percent of physicians who replied were considering an early exit from medicine.

This poll result was consistent with my own observation that early retirement online physician groups are burgeoning. Physician Side Gigs on Facebook, which seeks to help “physicians interested in pursuing opportunities outside of traditional clinical medicine…as a way to supplement or even replace their clinical income,” has over 50,000 members. Another Facebook group, Physicians on FIRE, aims to help physicians reach “Financial Independence. Retire Early” and has over 4000 members.

It is difficult to determine whether these physicians seeking early retirement are just wishfully complaining or actually planning an exit strategy. Many physicians answering the Twitter poll clarified that they loved treating and helping their patients but that the system had just become too difficult to deal with. Did this many physicians really want to leave the practice of medicine? What does that mean for our impending physician shortage? Why do so many of us feel the urge to get out?

Many discussions with disenchanted physicians ensued after that poll. In these discussions, I have found several common reasons that have pushed my colleagues to leave medicine.

Devaluation of Physicians on All Fronts

Devaluation appears to be happening on many fronts, according to my discussions with doctors online. There is the use of the term “provider” to replace “physician,” which more of us are finding offensive.

Mid-level providers who are cheaper for health systems to hire are replacing physicians. Reimbursements from commercial payers are declining. Health policy “experts” unfairly blame rising healthcare costs on physicians and have pushed legislators to find ways to lower physician compensation further. There are fewer physician meeting spaces in hospitals, such as doctors’ lounges or physician dining rooms, which used to serve as important spaces for physicians to commiserate and collaborate.

Overall, I sense great disappointment and anger among physicians about what many perceive to be increasing disregard for the tremendous amount of sacrifice physicians have made to complete their training. Physicians increasingly regret all of that time away from family or dropping their personal interests and hobbies during medical school and residency.Most shocking to me, however, is that physicians who speak out about such devaluation are often labeled “greedy doctors” by health policy “experts,” the press, and even fellow physicians (usually in the later stages of their career).

Loss of Autonomy and Independent Physician Opportunities

Personally, I’ve always wanted to be my own boss and I knew fairly early on in training that I wanted to enter private practice. I thought private practice would allow me to insulate myself from many of the forces that pushed my orthopedic surgery colleague to quit.

Mine is not the popular path, however, as the number of millennial physicians who are entering private practice has rapidly declined over the past decade. According to Medscape’s Residents Salary & Debt Report 2019, 22% of residents say they anticipate becoming either a practice owner or partner. According to a survey by the Physicians Foundation and Merritt Hawkins, only 31.4% of physicians identified as independent practice owners or partners in 2018. In 2012, independent physicians made up 48.5% of all doctors.

The survey even revealed that 58% of doctors do not think that hospital employment is a positive trend and concluded that “many physicians are dubious about the employed practice model even though they have chosen to participate in it, perhaps fearing that employment by hospitals will lead to a loss of clinical and administrative autonomy.”

I used to wonder why more of my millennial physician colleagues did not choose private practice as a career path and why so many were choosing hospital-based employment. A line I saw on Twitter sums it up: “Private practice is no longer about profitability. It’s about financial sustainability.” With greater consolidation within healthcare, independent doctors have lost much of their leverage when trying to negotiate fair rates with commercial payers.

In addition, the costs of purchasing an electronic health record and running a staff to deal with authorization and billing issues have made private practice extremely difficult. If more private practice opportunities existed, I am sure that my millennial colleagues would absolutely take them to maintain their independence. However, such independent practice opportunities continue to diminish, and millennial physicians may be pressured to take the only available positions: hospital employment with possible restrictions on autonomy.

Is Your Career Worth Your Own Life?

On average, one doctor a day in the United States ends his or her own life. Physicians commit suicide at a rate twice that of the general population, and over 1 million patients will lose their doctors to suicide every year. Pamela Wible, MD, who studied 1363 physician suicides, points out that “assembly-line medicine kills doctors” and that “pressure from insurance companies and government mandates further crush the souls of these talented people who just want to help their patients.”

Just a couple of months ago, my fellowship director forwarded me an email about a young orthopedic surgeon who had committed suicide, Thomas Fishler. He was known to be a brilliant surgeon whom colleagues and patients loved, and is survived by his young daughter. My fellowship director included in his email, “I know you have an awareness of the risks that those in our profession often face.”

Many physicians are crying for help and nobody is listening. Some sadly feel that the only way out is to end their lives.

Physician suicide is heartbreaking and screams crisis. What is driving brilliant doctors to the edge? I believe it’s further evidence of compounding external pressures that are making the practice of medicine increasingly intolerable. Many physicians are crying for help and nobody is listening. Some sadly feel that the only way out is to end their lives.

I get chills as I push the thought quickly out of my mind: Am I being subjected to this risk? All physicians have their tough days but I have never been anywhere close to being suicidal. But seriously—is it really worth it if I am at even a small risk of becoming that miserable?

Is There an Impending Crisis?

The average millennial physician completes training, looks around, and sees his or her profession in complete shambles. Burnout is rampant. Doctors are committing suicide daily. Many seem to be miserable over their lack of autonomy and loss of standing. The physician starts to take a hard look at the career they are about to embark on and begins to have serious doubts. Then the physician remembers that student loan debt. The average medical student loan debt in 2018, according to AAMC , was $198,000. There’s really no way out at this point; even if your job is going to make you miserable, you are going to push through because you’re on the hook.

And this is where I start to get seriously worried. We will have an entire generation of graduating physicians who will be subjected to forces that have never been present in medicine before. And these forces are actively causing distress and misery among some of my colleagues.

I know that my millennial colleagues have tremendous resilience and grit, as every generation of physicians has in the past. But how long will they put their heads down and fight against these ominous forces before they decide that they’ve had enough and jump ship just like my orthopedic colleague did?

Hope in Advocacy to Avert Crisis

Don’t get me wrong—practicing medicine is still the greatest privilege, and I know that every one of my millennial physician colleagues loves their patients dearly. I am honored that my patients entrust me to take away their pain and suffering in the operating room. I’ve studied and trained for 14 years to become an attending orthopedic spine surgeon; I’m not giving up this privilege that easily. And neither are most millennial physicians.

Millennials may be viewed as entitled, but many of us see that as comfort in advocating for themselves and questioning the status quo.” I believe that millennial physicians will not quietly accept the current state of affairs.

I see many impassioned millennial physician advocates becoming active in organizations like the Medical Society of the State of New York or the American Medical Association. These organizations already do excellent advocacy work, and I predict that millennial physicians will become a powerful force within such organizations to protect their profession. Through a unified voice, organized medicine is truly our strongest hope in enacting systemic changes that can prevent further physician demoralization and burnout.

We’re not giving up just yet. The crisis can be averted. Our patients and profession depend on it.

America’s healthiest and unhealthiest states

Cortney Moore noted that when it comes down to the popular saying that “health is wealth,” the states that have high revenue streams and median household incomes also have populations that are wellness-focused. Particularly, the states with the healthiest people are concentrated in the northern half of the U.S. and West Coast, according to America’s Health Rankings annual report conducted by the United Health Foundation.

The United Health Foundation analyzed the 50 states on five core categories, including model behaviors, community and environmental factors, public policies for health care and preventative care, clinical care and the overall health outcomes that result from the previous four.

America’s Health Rankings used a composite index of over 30 metrics to create its annual snapshot of statewide healthy populations, which ultimately helped the organization determine the healthiest to the unhealthiest.

Moreover, the report cited the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” in addition to individual genetic predispositions to disease.

The healthiest state is Vermont, which has moved up from 20th place in 1990 to first place in 2019, according to America’s Health Rankings data. In the past 15 years, the state has decreased its air pollution by 47 percent – with fine particles per cubic meter going down from 9.7 to 5.1 micrograms. Additionally, Vermont’s disparity in health status decreased from 49 percent to 17.4 percent in the past year. Other strengths the report noted include low incidences of chlamydia, violent crime and the percentage of uninsured residents.

For the 2019 fiscal year, with the exception to the month of December (which data has yet to be released for at the time of publication), the state of Vermont made over $955 million in revenue from general funds, according to the Agency of Administration. More than $113 million came from health care taxes and assessments that were collected between January 2019 and November 2019.

The median household income in Vermont is $60,076, according to data from the U.S. Census Bureau, which is close to the national median of $61,937. Moreover, average employee health care premium contributions for a family in the state is said to be $4,996, according to independent researchers at the Commonwealth Fund.

When it comes down to those who have government-funded health insurance plans, the Centers for Medicare and Medicaid Services do not have up-to-date figures since it is collected on a quinquennial basis. However, the agency found that Vermont reported a little over $5.7 million in 2015 for health care expenditures, as noted in an infographic by the Kaiser Family Foundation.

Outside the Green Mountain State, the other states that rounded out America’s Health Rankings top 10 are Massachusetts, Hawaii, Connecticut, Utah, New Hampshire, Minnesota, New Jersey, Washington and Colorado.

The unhealthiest state is Mississippi, which has maintained close to 50th place from 1990 to 2019, according to America’s Health Rankings data. Since 1993, low birthweight in Mississippi increased from 9.6 percent to 21 percent of live births. In the past five years, premature death increased by seven percent from 10,354 to 11,043 years lost to people who died before age 75. Premature mortality has increased on a national scale in addition to diabetes and obesity. Other challenges the report noted include a high cardiovascular death rate and percentage of children in poverty.

For the fiscal year of 2019, the state of Mississippi made $166 million in revenue collections, according to the Mississippi Legislative Budget Office, which surpassed the state’s estimate by $30.5 million.

The median household income in Mississippi is $43,567, according to data from the U.S. Census, which is $18,370 less than the national median. Average employee health care premium contributions for a family in the state is $5,133, according to the Commonwealth Fund, which is only $137 more than the premiums employees in Vermont are paying. But, when coupled with Mississippi’s lower median income, the cost of health coverage is substantial.

Mississippi also surpassed Vermont in spending on government-funded health insurance plans. The Centers for Medicare and Medicaid Services found that Mississippi reported over $21.5 million in 2015 for health care expenditures.

The other states that rounded out America’s Health Rankings bottom 10 were primarily in the South, including, South Carolina, Kentucky, Tennessee, West Virginia, Oklahoma, Alabama, Arkansas and Louisiana. Indiana was the only Midwestern state to land on the lower one-fifth of the unhealthiest states list.

On a national scale, American health is a mixed bag. Since 2012, smoking among adults has decreased from 24 percent to 16.1 percent, however, obesity among adults increased to 30.9 percent from 11 percent while diabetes among adults increased to 15 percent from 9.5 percent.

In the past three years, drug-related deaths have increased by 37 percent from 14 to 19.2 deaths per 100,000 people. When compared to America’s Health Rankings data from 2007, that is a 104 percent increase.

Environmental conditions have improved as air pollution decreased by 36 percent since 2003 and violent crime decreased by 50 percent since 1993. In the past four years, frequent mental distress increased from 11 percent to 13 percent, which has resulted in an increase of mental health providers, according to the report.

Infant mortality has decreased by 43 percent from 10.2 to 5.8 deaths per 1,000 live births in the past 29 years. However, low birth weight has increased by four percent from eight to 8.3 percent in the past three years, which also happens to be a 19 percent increase from 1993.

The average American spends more than $11,000 per year on health care and accounted for 17.7 percent of the U.S. GDP, according to estimates from the Centers for Medicare and Medicaid Services. With spending projected to grow at an average rate of 5.5 percent per year, the U.S. will reach nearly $6 trillion in health care spending by 2027.

Buttigieg’s health care plan would save money while Warren and Sanders plans would cost trillions, analysis finds

Associate Editor Adriana Belmont reported that Health care has been a contentious topic among the Democratic presidential candidates: Sens. Bernie Sanders (I-VT) and Elizabeth Warren (D-MA) support Medicare for All while Mayor Pete Buttigieg (D-IN) and former Vice President Joe Biden offer alternatives to universal health care.

A new analysis from the Committee for a Responsible Federal Budget (CRFB) took a look at the different plans and found that while each proposal would reduce the number of uninsured Americans, the least costly would be Buttigieg’s plan.

“Mayor Buttigieg’s plan would reduce deficits by $450 billion,” according to CFRB, adding that the policy would also “increase gross spending by $2.85 trillion, reduce costs by $1.2 trillion, and raise $2.1 trillion through direct and additional offsets.”

Through Buttigieg’s Medicare for All Who Want It plan, everyone would automatically be involved in universal health care coverage for those who are eligible. The policy would also expand premium subsidies for low-income individuals, cap out-of-pocket costs for seniors on Medicare, and limit what health care providers change for out-of-network care at double what Medicare pays for the same service. At the same time, those who still want to stay on private insurance can do so.

“This is how public alternatives work,” Buttigieg said. “They create a public alternative that the private sector is then forced to compete with.

CRFB estimated that the Indiana mayor’s plan would reduce the number of uninsured by between 20 to 30 million “by improving affordability and implementing auto-enrollment as well as retroactively enrolling and charging premiums to those who lack coverage.” 

‘Building on Obamacare’

Joe Biden’s health care plan, described as “building on Obamacare,” has an estimated gross cost of $2.25 trillion and would add $800 billion to deficits over 10 years. The CRFB also found that “it would reduce costs by $450 billion” and “raise $1 trillion through direct and additional offsets.”

Biden’s plan would reduce the number of uninsured by 15 to 20 million Americans and reduce national health expenditures by 1%. 

Some of his biggest revenue drivers in his plan include coverage expansion revenue feedback, which would create a public option, and end deductibility of prescription drug advertising. Additionally, his capital gains tax and “tax at death” would generate $550 billion.

‘Federal health expenditures would increase somewhat more’

Sen. Sanders, one of the original proponents of Medicare for All, has a plan that’s projected to add $13.4 trillion to deficits over a decade at a gross cost of $30.6 trillion. It would also raise $12.5 trillion in revenue through direct offsets and raise another $3 trillion through additional offsets.

His proposals to eliminate medical debt would cost $100 billion and would raise $1.7 trillion by reducing the costs of prescription drugs. To generate more money for the plan, Sanders would establish a 4% income surtax (projected to raise $4 trillion) and 7.5% employer payroll tax (estimated $4 trillion added). One significant cost in his plan, though, is offering universal long-term care — which would cost $29 trillion. 

“The reality is that Medicare for All will save American families thousands of dollars a year because they will no longer be paying premiums, deductibles and co-payments to greedy private health insurance companies,” Warren Gunnels, senior advisor for the Sanders campaign, told Yahoo Finance in a statement.

“If every major country on earth can guarantee health care to all and achieve better health outcomes, while spending substantially less per capita than we do, it is absurd for anyone to suggest that the United States of America cannot do the same.”

Overall, between 2021 to 2030, the CFRB estimated that Sanders’ plan would increase national health expenditures by 6%, “meaning that federal health expenditures would increase somewhat more than non-federal health spending would fall.”

‘Magical math’ or ‘the biggest middle class tax cut ever’?

Sen. Warren’s plan closely resembles Sanders’ in terms of cost. She stated her plan would cost $20.5 trillion in federal spending over a decade. CFRB found that the plan “would add $6.1 trillion to deficits over ten years under our central estimate.”

Experts disagree over the cost of Warren’s numbers, with one calling it “magical math” and another referring to Warren’s plan as “the biggest middle class tax cut ever.”

According to CRFB, the plan would increase gross spending by $31.75 trillion, reduce costs by $4.7 trillion, raise $14.2 trillion in revenue through direct offsets, and raise another $6.75 trillion through additional offsets. Her health care plan is estimated to increase costs by about 3%, but “the magnitude of these increases would decline over time.”

A major way to fund the plan would be through tax reform. By essentially eliminating tax breaks with private health insurers and requiring employers to contribute to her Medicare for All, she’s projected to generate an estimated $14.2 trillion. Other means of generating revenue for her plan include her wealth tax and a tax on bonds, stocks, and derivatives.

Both the Warren and Sanders plans would reduce the number of uninsured Americans by 30 to 35 million and “nearly eliminate” average premiums and out-of-pocket costs.

Patients can’t afford for doctors to misunderstand the healthcare business

Caroline Yao reported that When I was in medical school, my teachers started a lot of their stories with the same phrase:

“Back in my day, I still helped patients who couldn’t pay.”

“Back in my day, we didn’t have 100 checklists.”

“Back in my day, I didn’t need permission from insurance companies to do my job.”

“Back in my day, a yelp review couldn’t ruin my reputation.”

It happened so often that I wondered if I had shown up to the medical profession 30 years too late. Had I signed up for a sham fairytale?

I had thought doctors were autonomous, benevolent masters with kind voices and encyclopedic knowledge. After entering the field, I’ve found most young doctors struggle to balance convention versus empowerment, and doing good versus doing well. Doctors are the ugly stepchild of healthcare reform; too privileged to warrant help, but too powerless to do our jobs better.

I performed more than 2,500 surgeries during my residency training, and I am embarrassed to say that I do not know what a single one of my patients paid for their operations.

I later learned at the public hospital, surgeons were reimbursed $35 for each emergency appendectomy performed. Where did all that money go? Why didn’t the doctors question the system, or try to regain some control?

The provider will see you now

Somewhere along the way, my title as a doctor has been reduced to “provider,” and my worth dictated by administrators, insurance companies—and the government. The Hippocratic Oath I earnestly recited upon starting medical school is challenged everyday by a system of perverse incentives, where hospitals are paid more for treating the sick than keeping the patient well.

In 2013, 87% of graduating doctors felt uncomfortable with their knowledge of the business of medicine; 81% felt they lacked an understanding of healthcare legislation.

Is the answer that doctors should participate more in determining patient fees and reimbursement schedules? History shows that when doctors controlled payments more directly, graduated systems based on ability to pay were subtle but more ubiquitous. In the era of Aristotle, wealthy physicians did not accept payment, while poorer ones requested them. When 9th-century physician and scholoar Ishaq bin Ali al-Ruhawi wrote the first book of medical ethics, he described physicians as business owners who provided free services during times of patronage from caliphs and sultans. Throughout medieval Europe and during the Ottaman Empire, doctors treated the poor with the help of subsidies from royal courts and churches. Notable physicians such as Sir William Osler, legendary French surgeon and anatomist Guillaume Dupuytren, and physician and founder of Dickinson College, Benjamin Rush also charged rich and poor patients based on a self-made sliding scale.

Today, governments, universities, religious groups, and philanthropists are essentially modern-day barons who fund healthcare for the indigent through public hospitals, grants, and charitable work.

In the US, some physicians are granted partial and full student debt forgiveness from the government for working in underserved or rural communities. However, the majority of physicians who volunteer at free clinics, teaching hospitals, charities, or medical missions often do so only because their practice is flexible or lucrative enough to allow them both time away from paying jobs and the financial means to offer free services.

While physicians in private practice have autonomy over who they treat and how much they charge, physicians who work in hospital systems are more and more removed from managing the whole patient.

In 1983, 76% of doctors owned their own practice versus only 47% in 2016. Young physicians today are fundamentally unaware of the business side of medicine, and that’s bad news for everyone. As is the fact that medical students and residents are consistently and idealistically mentored to ignore the costs of materials and treatments we recommend.

We are taught to deliver care based on strict scientific evidence: the “gold standard” of care. Said gold standard, however, does not account for price, diminishing returns, convenience, or pain. The treatment that works best for a lab rat in a cage does not always translate to the most appropriate care for a person who has far more complex needs.

The cost of your health

A more pragmatic physician understands that patients who are underinsured, uninsured, or improperly educated will often forgo procedures, clinic visits, and medications when those interventions are too expensive or inconvenient.

Cost-conscious surgeons know that using instruments to tie stitches instead of hand-tying stitches can often result in a 10-fold cost savings without sacrificing quality.

I did not know how prohibitively expensive everyday surgical consumables cost until I went on humanitarian missions abroad and worked with surgical teams that could not afford these luxuries. I learned that hemostatic fabric we used like disposable napkins in the US cost $40 for a post-it sized square. A five-inch silicone band-aid costs $20. Bioengineered skin substitutes cost $10,000 for a palm-sized sheet.

My lack of price-awareness is fairly common. Many doctors have stopped accounting for the cost portion of a cost-benefit analysis.

And where doctors have leaned away from understanding cost, others have stepped in. Hospital administrators, governments, and insurance companies now manage the costs of healthcare. Correspondingly, physician compensation is estimated to be under 10% of total US national healthcare spending today. Overhead, administration, ancillary staff, malpractice insurance, and pharmaceuticals account for the majority of costs. For an appendectomy and associated care in 2018, the Medicare allowable compensation for a surgeon’s work is $394; meanwhile, healthcare watchdog organizations quote $13,000 as the fair price for hospitals to charge a patient and US hospitals bill an average of $31,000.

Most surgeons working in large hospitals are unaware of these numbers. They are therefore unable to tell patients how much they will be billed for a given operation. A surgeon in the 1830s in the company of the likes of Dr. Dupuytren would know these numbers.

Patients are often dismayed or surprised that their doctor cannot earnestly explain the cost-benefits of different treatments. A 2013 survey by the Journal of the American Medical Association found that 87% of graduating doctors felt uncomfortable with their knowledge of the business of medicine and 81% felt they lacked an understanding of healthcare legislation.  As surgeons, we have slowly let ourselves become exclusively technicians. Just like Aristotle and Plato said.

By turning our noses up at the business of medicine, we have lost ownership over our patients, and the agency to advocate for them. As Osler said, “The good physician treats the disease. The great physician treats the patient who has the disease.”

We as physicians and surgeons need to recover our identity and learn the business skills that our teachers have forgotten, but our forefathers stood up for.

As China’s Coronavirus Cases Rise, U.S. Agencies Map Out Domestic Containment Plans

Richard Harris reported that China has reported a large surge of cases of the novel coronavirus — upping its count from under 3,000 to over 4,500 as of Tuesday morning. More than 100 deaths have been reported. It is spreading rapidly in many provinces, and sporadic cases have now been reported in 18 other locations outside of China, including Australia, France and Canada.

In the United States, the case count remains at five — all people who had recently returned from Wuhan, China. And at a news conference Tuesday, top U.S. health officials reiterated that the disease — while serious — is not currently a threat to ordinary Americans.

“At this point, Americans should not worry for their own safety,” said Alex Azar, health and human services secretary, at the press briefing Tuesday.

While risk to most Americans remains low, Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, noted that “risk is dependent on exposure” and that health care workers or others who know they have been in contact with a person exposed to the virus should take precautions.

The federal government continues to adjust its approach to preventing the disease from taking hold in the U.S. On Monday night, the CDC and the State Department announced that a travel advisory recommending that Americans avoid travel to China when at all possible.

Airport screening is also being expanded from five airports to 20, with the goal of screening all passengers returning from China and letting people know what they should do if they fall ill after they get home.

The CDC is conducting contact investigations of people known to have been in contact with the five patients with confirmed infections, monitoring them for symptoms and testing them if concerning symptoms emerge.

Officials at the CDC are eager to get into China in order to help scientists there answer key questions — such as whether the virus can spread from people who don’t show any symptoms of illness. Azar said at the news conference that he had been pressing his counterpart in China for permission to send investigators.

That plea has been answered, at least to a certain extent. On Tuesday, the World Health Organization announced that it had the green light to send outside experts to China. It was not immediately clear whether that will include scientists from the CDC.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, explained that federal agencies are taking a three-pronged approach to respond to the novel coronavirus: developing and improving diagnostic tests, investigating experimental antiviral drugs, and working to develop a vaccine.

He said if it turns out that the virus can spread from someone who is not showing any symptoms, there would be some changes in the public health response. Similar coronaviruses from past outbreaks — severe acute respiratory syndrome and Middle East respiratory syndrome — did not spread in the absence of symptoms, but that doesn’t mean the new one will behave the same way. Viruses such as measles and influenza can be spread from people who aren’t showing signs of disease.

“Even if there is some asymptomatic transmission, in all the history of respiratory-borne viruses of any type, asymptomatic transmission has never been the driver of outbreaks,” Fauci said. “The driver of outbreaks has always been a symptomatic person.”

And lastly condolences go out to the Bryant family and the other members of the helicopter crash in southern California. Kobe will be sure missed but loss of kids really upsets a father like me the most!

Progress On Lung Cancer Drives Historic Drop In U.S. Cancer Death Rate, Obamacare and More Numbers

First some good news, which in today’s boiling kettle we all need. Cancer death rates in the United States took their sharpest drop on record between 2016 and 2017, according to an analysis by the American Cancer Society.

Richard Harris reported that the cancer death rates in the U.S. have been falling gradually for about three decades, typically about 1.5% a year. But during the latest study period, the cancer mortality rate dropped 2.2%, “the biggest single-year drop ever,” says Rebecca Siegel, scientific director for surveillance research at the cancer society.

“It seems to be driven by accelerating declines in lung cancer mortality,” Siegel says. That’s “very encouraging, because lung cancer is the leading cause of cancer death in the U.S., causing more deaths than breast, colorectal and prostate cancers combined.”

“This is unambiguously good news,” says Dr. H. Gilbert Welch, senior investigator with the Center for Surgery and Public Health, at Brigham and Women’s Hospital in Boston. He was not involved in the analysis.

What’s behind the decline? In part, smoking rates have fallen steadily, which means the biggest risk factor for lung cancer has fallen appreciably. New cancer treatments are also playing a role, Siegel says.

Advanced lung cancer, however, remains deadly. People diagnosed with lung cancer that has spread elsewhere in the body have only a 5% chance of surviving for five years. And many smokers and former smokers are not following the advice to get screened with a low-dose CT scan to catch cancer early.

In fact, a recent study found that only 4.4% of people eligible for this screening test (which under the Affordable Care Act is available at no cost) actually got screened in 2015. Nearly twice as many people instead got a test that has been found to be unsuited as a screen for lung cancer: a chest X-ray.

And others who didn’t fit the U.S. Preventive Services Task Force recommendations took the CT screening test anyway. “The number of adults inappropriately screened for lung cancer greatly exceeds the number screened according to the USPSTF recommendations,” the study notes.

Screening for cancer has played a controversial role in cancer trends. Mammography and the PSA blood test for prostate cancer do identify some cancers early, when treatment is usually more effective. But the tests also identify many growths that would never turn deadly — a phenomenon called “overdiagnosis.”

A paper published in the New England Journal of Medicine in October delves into that issue to help distinguish between cancer trends that are true improvements and trends simply due to changes in screening practices.

That issue plays out in the latest statistics. The reported number of prostate cancers surged in the 1980s as doctors started detecting it with the PSA test. That led to treating many prostate cancers that would never have turned deadly. Even so, the test caught a lot of cancers, and the death rate from prostate cancer fell at about 4% per year.

No longer. “The rapid declines in death rates over the past couple of decades actually halted,” Siegel says.

Siegel says that’s partly because reduced PSA screening, while preventing many unnecessary treatments, is also finding fewer treatable cancers. “I think there is a big need for a better test,” she says.

That plateau doesn’t surprise Welch, at Brigham and Women’s, who agrees that it might be time to reevaluate screening for prostate cancer. “I think we’ve gotten about the decline we’re going to get from screening and treatment,” he says. Some types of prostate cancer are more treatable than others and with recent improvements, he says, “we’ve gotten the low-hanging fruit.”

Improvements in cancer treatment are apparent when it comes to melanoma, a skin cancer that’s far less common than prostate or lung cancer. The new statistics show that melanoma death rates have been dropping by 7% per year. The report attributes this largely to anti-cancer drugs called checkpoint inhibitors and other new drugs. Some 92% of people diagnosed with this cancer are still alive five years later (compared with 19% of those diagnosed with lung cancer).

While the report measures trends in cancer rates (which are measured as deaths per 100,000 people), that’s not the same as tracking the actual number of cancer cases and deaths. Cancer is mostly a disease of older people, and the U.S. population is aging rapidly. So, while rates are declining, the absolute number of cancer deaths is not.

“We have more than 600,000 deaths from cancer in this country every year, and that number continues to grow,” Siegel says.

And with treatments getting progressively more expensive, that’s a challenge not just for individuals but for the entire health care system.

A detailed analysis of the statistics is being published Wednesday in CA: A Cancer Journal for Clinicians.

Study Finds Talcum Powder Not Likely A Risk For Ovarian

And some more god news Patti Neighmond noted that in recent years, women have taken talcum powder manufacturers to court over concerns that the use of the product in the genital area could cause ovarian cancer. Now, a new study finds no meaningful association between using talc-based or other powders and ovarian cancer.

Researchers from NIH’s National Institute of Environmental Health Sciences and the National Cancer Institute conducted the largest study to date of genital powder use and ovarian cancer. The study, published Tuesday in JAMA, used data from 252,745 women who answered questions about whether they used powder on their genitals. This was a pooled analysis of four large studies gathering data about the frequency and length of time women used the powder.

According to epidemiologist Katie O’Brien who headed the study, women report applying the powder either directly on their genital area or on sanitary napkins, tampons, underwear or diaphragms. O’Brien doesn’t know exactly which type of powder women used. It could have been talcum powder alone, cornstarch alone or a combination of both.

The research finds that women who had ever used powder had an 8% increased risk of ovarian cancer compared to those who never used it. “That is not a statistically significant increase” says O’Brien. And she adds that this increase needs to be understood in context. Ovarian cancer is very rare and the lifetime risk of getting it is 1.3% so an increase of 8% to that is “small.” O’Brien says it represents an estimated 0.09% increase in risk by age 70.

But among the subset of women who had their uterus and fallopian tubes intact, their increased risk of ovarian cancer from using powder in their genital area was 13% — which is an estimated 0.15% increase in risk by age 70 and is still considered a very small increase.

Unlike most other studies of talc and ovarian cancer, which focused on women already diagnosed with cancer, this study was prospective, and asked about powder use before study subjects had developed ovarian cancer. This means the study is free from recall bias, says O’Brien. It removes the likelihood that study subjects “search for reasons why they have ovarian cancer, and may over-report certain things they have heard may be associated with it.”

Rates of powder use have declined over the last 50 years, yet it remains a routine practice for some women, says Dr. Dana Gossett, a professor of obstetrics and gynecology at the University of California, San Francisco. She wrote an editorial accompanying the study but was not involved in the study itself.

“Women have used powders for genital hygiene for decades to absorb odor and moisture,” she says.

Earlier investigations of an association between the use of talc-containing powders for genital hygiene and epithelial ovarian cancer risks have provided inconsistent results, says Gossett and have resulted in an “ongoing controversy.” Concerns have been raised about possible contamination of mineral talc with asbestos, a known cancer risk. Most powder products include some mineral talc.

Researchers say it’s been hypothesized that the powder could induce an inflammatory response by irritating epithelial ovarian tissue or fallopian tubes directly which, in turn, could set off a cascade of increased oxidative stress levels, DNA damage and cell division, all of which could contribute to carcinogenesis.

Gossett says the new study finding “doesn’t really support any association [of powder use with ovarian cancer].”

“No study can ever say definitively what the cause of cancer is, but this study at least shows there’s not a substantial increase in ovarian cancer risk,” she says.

The study has several limitations. Researchers were not able to document how frequently or how long women used powder nor were they able to identify exactly what ingredients were in the powder. It also included mostly white women. Anecdotally, black women are more likely to use baby powder.

Obstetrician Gossett says the study findings should be “reassuring to women that if they are choosing to use powders on their genitals that they’re not doing something horrendous.”

Gossett also notes that due to the very small number of cancer cases in the data, the study was “underpowered.” She suggests that future analyses would be strengthened by focusing on women with intact reproductive tracts, with particular attention to timing and duration of exposure to powder in the genital area.

In the meantime, since there’s no medical reason to use talcum powder, researcher O’Brien suggests women weigh perceived benefit with possible risk. Study participants will continue to be followed to track ovarian cancer development in the future, she says.

The Staggering Cost of US Health Care Bureaucracy

Yuval Posenberg, reporter for the Fiscal Times, wrote that seemingly everyone has a horror story to tell about dealing with the bureaucracy of the U.S. health care system, from mundane matters like medical records to financial fights over surprise medical bills or insurance claims.

Those individual experiences come at a high collective cost, according to a new study published in the Annals of Internal Medicine: U.S. health insurers and providers spent $812 billion on administration in 2017, representing more than a third of national health expenditures, or double the 17% percent that Canada spends under its single-payer system. The U.S. administrative costs translate to nearly $2,500 per person — or almost five times as high as in Canada.

“The gap in health administrative spending between the United States and Canada is large and widening, and it apparently reflects the inefficiencies of the U.S. private insurance–based, multipayer system,” the study’s authors conclude. “The prices that U.S. medical providers charge incorporate a hidden surcharge to cover their costly administrative burden.”

The study finds that U.S. could have saved more than $600 billion in 2017 if it were able to cut its administrative costs to match Canada’s. “The difference between Canada and the U.S. is enough to not only cover all the uninsured but also to eliminate all the copayments and deductibles, and to amp up home care for the elderly and disabled,” Dr. David Himmelstein, a professor at the CUNY School of Public Health at Hunter College and co-author of the study, told Time. “And frankly to have money left over.”

Why it matters: This isn’t the first study to show that the U.S. system has higher administrative costs than other countries, but it is the first major study calculating those system-wide costs in almost two decades. The spending disparity detailed in the study “could challenge some assumptions about the relative efficiency of public and private healthcare programs,” writes Melissa Healy of the Los Angeles Times. “It could also become a hot political talking point on the American campaign trail as presidential candidates debate the pros and cons of government-funded universal health insurance.”

A steep rise in U.S. costs: Administrative costs have grown in both the U.S. and Canada over the last 20 years, but the increase in the United States has been much higher, mostly as the result of insurance overhead. “The study showed that private insurers contributed to most of the increase in administrative costs between 1999 and 2017,” Modern Healthcare’s Rachel Cohrs reports. “Of the 3.2 percentage point increase in administrative costs as a share of overall health spending, 2.4 percentage points were due to the expanding role that private insurers have assumed in Medicare and Medicaid.”

The insurance industry response: America’s Health Insurance Plans, a group representing private health insurance companies, told the Los Angeles Times that government-run systems aren’t as efficient as private ones, citing a recent report by the Medicare Payment Advisory Commission, an independent body that advises Congress, that found that private Medicare Advantage plans deliver benefits at 88% of the cost of traditional Medicare. “Study after study continues to demonstrate the value of innovative solutions brought by the free market,” AHIP said in its statement. “In head-to-head comparisons, the free market continues to be more efficient than government-run systems.”

The researchers are single-payer advocates: Himmelstein and one of his co-authors, Dr. Steffie Woolhandler, also of the CUNY School of Public Health at Hunter College, have long advocated for a single-payer health-care system in the United States. They co-founded the group Physicians for a National Health Program and have been unpaid policy advisors to Sen. Bernie Sanders and have coauthored research manuscripts with Sen. Elizabeth Warren. Both senators are calling for a transition to a single-payer Medicare-for-All system. But the researchers say that their conclusions in the new study are based on the data — and that their estimates of U.S. administrative costs are likely conservative.

“It’s actually the data that guided us to the solution, the solution didn’t give rise to the data,” Himmelstein said, according to Modern Healthcare.

Himmelstein also says that, while it may be possible to reduce administrative costs without switching to a single-payer system, the benefits would be much smaller. “We could streamline the bureaucracy to some extent with other approaches, but you can’t get nearly the magnitude of savings that we could get with a single payer,” he told Time.

‘Obamacare’ mandate: hot for lawyers, ho-hum to consumers

Ricardo Alonso-Zaldivar of the Associated Press reported that the repeal of an unpopular fine for people without health insurance has had little impact on “Obamacare” sign-ups or premiums, a gap between the real world and legal arguments from conservatives again challenging the Affordable Care Act.

The 10-year-old law has proved more resilient than its creators or detractors imagined, even as the Supreme Court considers whether to take up the latest effort to roll it back.

Opponents argue that the constitutionality of the entire 900-page law hinges on the now-toothless penalty for not having health insurance. Collected as a tax by the IRS, the penalty was intended to enforce the law’s “individual mandate” that Americans be insured. A previous Republican-led Congress set the fines to $0, effective last year.

“We’ve gotten a lot of evidence by now about what the market looks like without a mandate penalty, and on the whole it looks pretty stable, which is surprising because that’s not what most people would have expected when the ACA was being written,” said Cynthia Cox, who directs research on the health law for the nonpartisan Kaiser Family Foundation.

A Kaiser study released this week found that removal of the penalty pushed premiums up about 5% going into 2019, but the bottom line was a wash because of other factors. Insurers appeared to be making healthy profits.

The penalty was thought to be critical when the law was being written in 2009-2010. The idea was to nudge healthy people to sign up, helping keep premiums in check. But Cox said there’s no indication that healthy people have dropped out in droves. In one telling statistic, the Kaiser study found that average hospital days per 1,000 people enrolled dipped slightly in 2019, even after the penalty was eliminated.

Partial sign-up numbers for 2020 released Wednesday by the government point to stability. Nearly 8.3 million people enrolled in the 38 states served by the federal HealthCare.gov website. That’s down only about 2% from last year, when one additional state was using HealthCare.gov. A final count including that state — Nevada — and others that run their own sign-up efforts is expected by the spring.

The insurance mandate was the central issue when the Supreme Court first upheld the health care law in 2012, over a year before HealthCare.gov opened for business.

Chief Justice John Roberts cast the key vote in that 5-4 decision. He found that Congress lacked constitutional authority to require that Americans have health insurance. But because Congress has broad powers to levy taxes, Roberts ruled that a tax on people who did not purchase coverage offered them was constitutional. That allowed the law to survive what’s still seen as its most serious legal challenge.

Kathleen Sebelius, health secretary for President Barack Obama, said in 2012 that it was generally accepted that the insurance mandate was part of a three-legged stool key to stable markets. The other two legs were taxpayer-provided subsidies for premiums and a guarantee that patients with preexisting medical conditions could no longer be turned down or charged more.

“It was thought that the trade-off for changing the rules on preexisting conditions would have to be … some penalty incentive so you would get healthy people in the pool, along with not-healthy people,” Sebelius said. “What became clear when the law went into effect (in 2014) is that the subsidies in many ways provided a greater incentive for people get health insurance.”

Those subsides are designed so that low- and moderate-income households only spend a fixed percentage of their incomes on premiums, shielding consumers from high sticker prices.

Cox agreed that the law’s “carrots” seem to have made more of a difference than its “stick.”

Fast-forward to 2018 and a coalition of conservative states led by Texas won a lower court decision that the insurance mandate was still critical, in a legal and constitutional sense.

U.S. District Court Judge Reed O’Connor in Texas ruled that by zeroing out the tax penalty, Congress rendered the insurance mandate unconstitutional, and without it the entire health law must fall. President Donald Trump agreed.

Recently, a federal appeals court in New Orleans agreed with O’Connor that an unenforceable insurance mandate is unconstitutional. But the appeals court sent the case back to him to see whether other parts of the law can stand.

Defending the law, a coalition of Democratic-led states, along with the U.S. House, appealed to the Supreme Court, seeking a fast-track decision amid this year’s presidential election. The court has asked lawyers for the conservative states to respond by Friday on the timing question.

University of Michigan law professor Nicholas Bagley said the stability of the health insurance markets exposes “the artificiality” of the conservatives’ argument.

“It really goes to show how ridiculous it is to claim that Congress understood the mandate to be so essential that if it were to be red-lined out, the rest of the law would have to fall,” said Bagley.

Not so fast, said Andrew Schlafly, a lawyer representing groups siding with Texas and the other GOP-led states opposing the law.

“The question is not whether in reality (the ACA) can work without the mandate,” said Schlafly. “The test is whether it was intended to work without the mandate.

“Theory does matter to these Supreme Court justices,” he added, “and they do take theory seriously.”

ObamaCare still working despite individual mandate’s repeal

Megan Henney noted that one year after Republicans repealed the Affordable Care Act’s individual mandate, President Barack Obama’s signature health care law remains surprisingly stable and profitable for insurers.

When Republicans gutted the ACA in the 2017 Tax Cuts and Jobs Act, eliminating the provision that required Americans to either buy health insurance or pay a fine, critics warned that decision would cause younger and healthier people to flee from the marketplace, leaving sicker, more expensive patients, remaining and causing the market to enter a “death spiral.”

But a report released by the Kaiser Family Foundation on Monday found that despite the removal of the mandate, those fears are largely unfounded.

Individual enrollment fell by 5 percent between the first quarter of 2018 and 2019, but the relatively modest growth in claims costs at the beginning of 2019 indicates that enrollment declines and policy changes did not cause healthy individuals to flee the market. In fact, the average number of days enrollees spent in a hospital in the first nine months of 2019 was slightly lower than inpatient days in the previous four years.

“Results from the first nine months of 2019 suggest that the individual market remains profitable and stable despite the effective repeal of the individual mandate,” the analysis said.

A key measure of insurers’ financial strength, margins — the average amount by which premium income exceeds claims costs per each enrollee in a given month — are the healthiest they’ve been in nearly eight years. (Insurer financial performance dipped slightly at the end of 2019, but the margins remained higher than all other previous years through 2017).

“These data suggest that insurers in this market remain on average financially healthy,” the report said.

The report comes amid attacks by Republicans and President Trump on arguably the biggest legislative accomplishment of the Obama administration.

Most recently, the U.S. Court of Appeals for the Fifth Circuit, in the case of Texas v. Azar, struck down the individual mandate as unconstitutional, though it did not invalidate the rest of the law, leaving its fate, once again, in limbo. The ruling was issued almost exactly one year after Judge Reed O’Connor in Fort Worth, Texas, struck down the entire law.

A coalition of Democratic states, led by California Attorney General Xavier Becerra, has made it clear that it intends to challenge the appeals court decision by petitioning the Supreme Court to take the case.

The ultimate outcome of the lawsuit will affect millions of Americans, and the repeal of the 9-year-old law could leave up to 32 million people without health insurance by 2026, according to a Congressional Budget Office report from 2017 about the effects of repealing the ACA.

I’m still confused as to why Bernie Sanders and Elizabeth Warren are pushing Medicare for All and not fixing the ACA/Obamacare. Let’s see with tomorrow’s debate whether we get and more suggestions. Moreover, why hasn’t the Republicans when they had the majority on the House and the Democrats now that they have control in the House, why no one party has tried hard to fix the healthcare problem. Politics and more political “strategies” continue to get in the way of the real solution.