Category Archives: Health Care

Poll: Support for ‘Medicare-for-all’ fluctuates with details and Medicaid. What is the Answer​?

50065252_1872612819535035_7021591760191094784_nSo, one of the options that the Democrats are pushing is “Medicare-for-All.” But do the voters like the idea? Ricardo Alonso-Zaldivar noted that Americans like the idea of “Medicare-for-all,” but support flips to disapproval if it would result in higher taxes or longer waits for care. Then how will the plan be financed?

That’s a key insight from a national poll released Wednesday by the nonpartisan Kaiser Family Foundation. It comes as Democratic presidential hopefuls embrace the idea of a government-run health care system, considered outside the mainstream of their party until Vermont independent Sen. Bernie Sanders made it the cornerstone of his 2016 campaign. President Donald Trump is opposed, saying “Medicare-for-all” would “eviscerate” the current program for seniors.

The poll found that Americans initially support “Medicare-for-all,” 56 percent to 42 percent.

However, those numbers shifted dramatically when people were asked about the potential impact, pro, and con.

Support increased when people were told “Medicare-for-all” would guarantee health insurance as a right (71 percent) and eliminates premiums and reduce out-of-pocket costs (67 percent).

But if they were told that a government-run system could lead to delays in getting care or higher taxes, support plunged to 26 percent and 37 percent, respectively. Support fell to 32 percent if it would threaten the current Medicare program.

“The issue that will really be fundamental would be the tax issue,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who reviewed the poll. He pointed out those state single-payer efforts in Vermont and Colorado failed because of concerns about the tax increases needed to put them in place.

There doesn’t seem to be much disagreement that a single-payer system would require tax increases since the government would take over premiums now paid by employers and individuals as it replaces the private health insurance industry. The question is how much.

Several independent studies have estimated that government spending on health care would increase dramatically, in the range of about $25 trillion to $35 trillion or more over a 10-year period. But a recent estimate from the Political Economy Research Institute at the University of Massachusetts in Amherst suggests that it could be much lower. With significant cost savings, the government would need to raise about $1.1 trillion from new revenue sources in the first year of the new program.

House Budget Committee Chairman John Yarmuth, D-Ky., has asked the Congressional Budget Office for a comprehensive report on single-payer. The CBO is a nonpartisan outfit that analyzes the potential cost and impact of legislation. Its estimate that millions would be made uninsured by Republican bills to repeal the Affordable Care Act was key to the survival of President Barack Obama’s health care law.

Mollyann Brodie, director of the Kaiser poll, said the big swings in approval and disapproval show that the debate over “Medicare-for-all” is in its infancy. “You immediately see that opinion is not set in stone on this issue,” she said.

Indeed, the poll found that many people are still unaware of some of the basic implications of a national health plan.

For example, most working-age people currently covered by an employer (55 percent) said they would be able to keep their current plan under a government-run system, while 37 percent correctly answered that they would not.

There’s one exception: Under a “Medicare-for-all” idea from the Center for American Progress employers and individuals would have the choice of joining the government plan, although it wouldn’t be required. Sanders’ bill would forbid employers from offering coverage that duplicates benefits under the new government plan.

“Medicare-for-all” is a key issue energizing the Democratic base ahead of the 2020 presidential election, but Republicans are solidly opposed.

“Any public debate about ‘Medicare-for-all’ will be a divisive issue for the country at large,” Brodie said.

The poll indicated widespread support for two other ideas advanced by Democrats as alternatives to a health care system fully run by the government.

Majorities across the political spectrum backed allowing people ages 50-64 to buy into Medicare, as well as allowing people who don’t have health insurance on the job to buy into their state’s Medicaid program.

Separately, another private survey out Wednesday finds the uninsured rate among U.S. adults rose to 13.7 percent in the last three months of 2018. The Gallup National Health and Well-Being Index found an increase of 2.8 percentage points since 2016, the year Trump was elected promising to repeal “Obamacare.” That would translate to about 7 million more uninsured adults.

Government surveys have found that the uninsured rate has remained essentially stable under Trump.

The Kaiser Health Tracking Poll was conducted Jan. 9-14 and involved random calls to the cellphones and landlines of 1,190 adults. The margin of sampling error for all respondents is plus or minus 3 percentage points.

Trump Seeks Action To Stop Surprise Medical Bills

A healthcare reporter, Emmarie Huettman reported that President Trump instructed administration officials Wednesday to investigate how to prevent surprise medical bills, broadening his focus on drug prices to include other issues of price transparency in health care.

Flanked by patients and other guests invited to the White House to share their stories of unexpected and outrageous bills, Trump directed his health secretary, Alex Azar, and labor secretary, Alex Acosta, to work on a solution, several attendees said.

“The pricing is hurting patients, and we’ve stopped a lot of it, but we’re going to stop all of it,” Trump said during a roundtable discussion when reporters were briefly allowed into the otherwise closed-door meeting.

David Silverstein, the founder of a Colorado-based nonprofit called Broken Healthcare who attended, said Trump struck an aggressive tone, calling for a solution with “the biggest teeth you can find.”

“Reading the tea leaves, I think there’s a big change coming,” Silverstein said.

Surprise billing, or the practice of charging patients for care that is more expensive than anticipated or isn’t covered by their insurance, has received a flood of attention in the past year, particularly as Kaiser Health News, NPR, Vox and other news organizations have undertaken investigations into patients’ most outrageous medical bills.

Attendees said the 10 invited guests — patients as well as doctors — were given an opportunity to tell their story, though Trump didn’t stay to hear all of them during the roughly hourlong gathering.

The group included Paul Davis, a retired doctor from Findlay, Ohio, whose daughter’s experience with a $17,850 bill for a urine test after back surgery was detailed in February 2018 in KHN-NPR’s first Bill of the Month feature.

Davis’ daughter, Elizabeth Moreno, was a college student in Texas when she had spinal surgery to remedy debilitating back pain. After the surgery, she was asked to provide a urine sample and later received a bill from an out-of-network lab in Houston that tested it.

Such tests rarely cost more than $200, a fraction of what the lab charged Moreno and her insurance company. But fearing damage to his daughter’s credit, Davis paid the lab $5,000 and filed a complaint with the Texas attorney general’s office, alleging “price gouging of staggering proportions.”

Davis said White House officials made it clear that price transparency is a “high priority” for Trump, and while they didn’t see eye to eye on every subject, he said he was struck by the administration’s sincerity.

“These people seemed earnest in wanting to do something constructive to fix this,” Davis said.

Dr. Martin Makary, a professor of surgery and health policy at Johns Hopkins University who has written about transparency in health care and attended the meeting, said it was a good opportunity for the White House to hear firsthand about a serious and widespread issue.

“This is how most of America lives, and [Americans are] getting hammered,” he said.

Trump has often railed against high prescription drug prices but has said less about other problems with the nation’s health care system. In October, shortly before the midterm elections, he unveiled a proposal to tie the price Medicare pays for some drugs to the prices paid for the same drugs overseas, for example.

Trump, Azar, and Acosta said efforts to control costs in health care were yielding positive results, discussing, in particular, the expansion of association health plans and the new requirement that hospitals post their list prices online. The president also took credit for the recent increase in generic drug approvals, which he said would help lower drug prices.

Discussing the partial government shutdown, Trump said Americans “want to see what we’re doing, like today we lowered prescription drug prices, the first time in 50 years,” according to a White House pool report.

Trump appeared to be referring to a recent claim by the White House Council of Economic Advisers that prescription drug prices fell last year.

However, as STAT pointed out in a recent fact check, the report from which that claim was gleaned said “growth in relative drug prices has slowed since January 2017,” not that there was an overall decrease in prices.

Annual increases in overall drug spending have leveled off as pharmaceutical companies have released fewer blockbuster drugs, patents have expired on brand-name drugs and the waning effect of a spike driven by the release of astronomically expensive drugs to treat hepatitis C.

Drugmakers were also wary of increasing their prices in the midst of growing political pressure, though the pace of increases has risen recently.

Since Democrats seized control of the House of Representatives this month, party leaders have rushed to announce investigations and schedule hearings dealing with health care, focusing in particular on drug costs and protections for those with preexisting conditions.

Last week, the House Oversight Committee announced a “sweeping” investigation into drug prices, pointing to an AARP report saying the vast majority of brand-name drugs had more than doubled in price between 2005 and 2017.

The Ground Game for Medicaid Expansion: ‘Socialism’ or a Benefit for All?

One of the other options is that of expanding Medicaid but is that socialism or a benefit for all. Michael Ollove noted that a yard sign in Omaha promotes Initiative 427, which would expand Medicaid in Nebraska. Voters in the red states of Idaho and Utah also will decide whether to join 33 states and Washington, D.C., in extending Medicaid benefits to more low-income Americans as envisioned by the Affordable Care Act. Montana voters will decide whether to make expansion permanent.

Nati Harnik noted that on a sun-drenched, late October afternoon, Kate Wolfe and April Block are canvassing for votes in a well-tended block of homes where ghosts and zombies compete for lawn space with Cornhusker regalia. Block leads the way with her clipboard, and Wolfe trails behind, toting signs promoting Initiative 427, a ballot measure that, if passed, would expand Medicaid in this bright red state.

Approaching the next tidy house on their list, they spot a middle-aged woman with a bobbed haircut pacing in front of the garage with a cellphone to her ear.

Wolfe and Block pause, wondering if they should wait for the woman to finish her call when she hails them. “Yes, I’m for Medicaid expansion,” she calls. “Put a sign up on my lawn if you want to.” Then she resumes her phone conversation.

Apart from one or two turndowns, this is the sort of warm welcome the canvassers experience this afternoon. Maybe that’s not so surprising even though this is a state President Donald Trump, an ardent opponent of “Obamacare,” or the Affordable Care Act, carried by 25 points two years ago.

Although there has been no public polling, even the speaker of the state’s unicameral legislature, Jim Scheer, one of 11 Republican state senators who signed an editorial last month opposing the initiative, said he is all but resigned to passage. “I believe it will pass fairly handily,” he told Stateline late last month.

Anne Garwood (left), a tech writer, and April Block, a middle school teacher, review voter lists in preparation for canvassing an Omaha neighborhood in favor of Initiative 427, which would expand Medicaid in Nebraska.

The Pew Charitable Trusts

Bills to expand eligibility for Medicaid, the health plan for the poor run jointly by the federal and state governments, have been introduced in the Nebraska legislature for six straight years. All failed. Senate opponents said the state couldn’t afford it. The federal government couldn’t be counted on to continue to fund its portion. Too many people were looking for a government handout.

Now, voters will decide for themselves.

Nebraska isn’t the only red state where residents have forced expansion onto Tuesday’s ballot. Idaho and Utah voters also will vote on citizen-initiated measures on Medicaid expansion. Montana, meanwhile, will decide whether to make its expansion permanent. The majority-Republican legislature expanded Medicaid in 2015, but only for a four-year period that ends next July.

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Polling in those three states indicates a majority supports expanding Medicaid. Like Nebraska, all are heavily Republican states easily captured by Trump in 2016.

Last year’s failed attempt by Trump and congressional Republicans to unravel Obamacare revealed the popularity of the ACA with voters. Health policy experts said it also helped educate the public about the benefits of Medicaid, prompting activists in the four states to circumvent their Republican-led legislatures and take the matter directly to the voters.

Activists also were encouraged by the example of Maine, where nearly 60 percent of voters last year approved Medicaid expansion after the state’s Republican governor vetoed expansion bills five times.

“Medicaid has always polled well,” said Joan Alker, executive director of the Center for Children and Families at Georgetown. “When you explain what it does, they think it’s a good idea. What has changed is the intensity and growing recognition that states without expansion are falling further behind, especially in rural areas where hospitals are closing at an alarming rate.

“And all of the states with these ballot initiatives this year have significant rural populations.”

For many in Nebraska, the argument — advanced in one anti-427 television ad — that Medicaid is a government handout to lazy, poor people simply doesn’t square with what they know.

“These aren’t lazy, no-good people who refuse to work,” said Block, a middle school teacher, in an exasperating tone you can imagine her using in an unruly classroom. “They’re grocery store baggers, home health workers, hairdressers. They are the hardest workers in the world, who shouldn’t have to choose between paying for rent or food and paying for medicine or to see a doctor.”

Extending Benefits to Childless Adults

The initiative campaign began after the Nebraska legislature refused to take up expansion again last year. Its early organizers were, among others, a couple of Democratic senators and a nonprofit called Nebraska Appleseed.

Calling itself “Insure the Good Life,” an expansion of the state slogan, the campaign needed nearly 85,000 signatures to get onto the ballot. In July, the group submitted 136,000 signatures gathered from all 93 Nebraska counties.

The initiative would expand Medicaid to childless adults whose income is 138 percent of the federal poverty line or less. For an individual in Nebraska, that would translate to an income of $16,753 or less. Right now, Nebraska is one of 17 states that don’t extend Medicaid benefits to childless adults, no matter how low their income.

Under Medicaid expansion, the federal government would pay 90 percent of the health care costs of newly eligible enrollees, and the state would be responsible for the rest. The federal match for those currently covered by Medicaid is just above 52 percent.

The Nebraska Legislative Fiscal Office, a nonprofit branch of the legislature, found in an analysis that expansion would bring an additional 87,000 Nebraskans into Medicaid at an added cost to the state of close to $40 million a year. The current Medicaid population in Nebraska is about 245,000.

The federal government would send an additional $570 million a year to cover the new enrollees. An analysis from the University of Nebraska commissioned by the Nebraska Hospital Association, a backer of the initiative, found the new monies also would produce 10,800 new jobs and help bolster the precarious financial situation of the state’s rural hospitals.

For economic reasons alone, not expanding makes little sense, said state Sen. John McCollister, one of two Republican senators openly supporting expansion and a sponsor of expansion bills in the legislature, over coffee in an Omaha cafe one day recently.

“Nebraska is sending money to Washington, and that money is being sent back to 33 other states and not to Nebraska,” he said. “It’s obviously good for 90,000 Nebraskans by giving them longevity and a higher quality of life, but it also leads to a better workforce and benefits rural hospitals that won’t have to spend so much on uncompensated care.”

He said the state could easily raise the necessary money by increasing taxes on medical providers, cigarettes and internet sales. If 427 passes, those will be decisions for the next legislature.

Among the measure’s opponents are Americans for Prosperity, a libertarian advocacy group funded by David and Charles Koch that has been running radio ads against the initiative. Jessica Shelburn, the group’s state director in Nebraska, said her primary concern is that expansion would divert precious state resources and prompt cutbacks in the current optional services Medicaid provides.

“While proponents have their hearts in the right place,” Shelburn said, “we could end up hurting the people Medicaid is intended to help.”

Georgetown’s Alker, however, said that no expansion state has curtailed Medicaid services.

When the Affordable Care Act passed in 2010, it mandated that all states expand Medicaid, but a 2012 U.S. Supreme Court ruling made expansion optional for the states. As of now, 33 states and Washington, D.C., have expanded, including states that tend to vote Republican, such as Alaska, Arkansas, and Indiana.

Expansion is not an election issue only in the states with ballot initiatives this year. Democratic gubernatorial candidates are making expansion a major part of their campaigns in Florida and Georgia.

Ashley Anderson, a 25-year-old from Omaha with epilepsy, is one of those anxiously hoping for passage in Nebraska. A rosy-faced woman, she wears a red polo shirt from OfficeMax, where she works part-time for $9.50 an hour in the print center. She aged out of Medicaid at 19, and her single mother can’t afford a family health plan through her employer.

Since then, because of Anderson’s semi-regular seizures, she says she can’t take a full-time job that provides health benefits, and private insurance is beyond her means.

Because Anderson also can’t afford to see a neurologist, she is still taking the medication she was prescribed as a child, even though it causes severe side effects.

Not long ago, Anderson had a grand mal seizure, which entailed convulsions and violent vomiting, and was taken by ambulance to the emergency room. That trip left her $2,000 in debt. For that reason, she said, “At this point, I won’t even call 911.”

Anderson might well qualify for Social Security disability benefits, which would entitle her to Medicaid, but she said the application process is laborious and requires documentation she does not have. As far as she is concerned, the initiative is her only hope for a change.

“You know what, I even miss having an MRI,” she said. “I’m supposed to have one every year.” She can’t remember the last time she had one.

For the uninsured, the alternatives are emergency rooms or federally qualified health centers, which do not turn away anyone because of poverty.

While the clinics provide primary care, dental care, and mental health treatment, they cannot provide specialty care or perform diagnostic tests such as MRIs or CAT scans, said Ken McMorris, CEO of Charles Drew Health Center, the oldest community health center in Nebraska, which served just under 12,000 patients last year.

Almost all its patients have incomes below 200 percent of poverty, McMorris said. Many have little access to healthy foods and little opportunity for exercise.

William Ostdiek, the clinic’s chief medical officer, said he constantly sees patients with chronic conditions such as diabetes and cardiovascular disease whose symptoms are getting worse because they cannot afford to see specialists.

“It’s becoming a vicious cycle,” he said. “They face financial barriers to the treatments they need, which would enable them to have full, productive lives. Instead, they just get sicker and sicker.”

Expansion, McMorris said, would make all the difference for many of those patients.

Some county officials also hope for passage. Mary Ann Borgeson, a Republican county commissioner in Douglas County, which includes Omaha, said her board has always urged the legislature to pass expansion. “Most people don’t understand — for counties, the Medicaid is a lifeline for many people who otherwise lack health care.”

Consequently, she said, the county pays about $2 million a year to reimburse providers for giving care to people who don’t qualify for Medicaid and can’t afford treatment, money that would otherwise be in the pockets of county residents.

‘That Is Socialism’

Insure the Good Life has raised $2.2 million in support of 427, according to campaign finance reports and Meg Mandy, who directs the campaign. Significant contributions have come from outside the state, particularly from Families USA, a Washington-based advocacy organization promoting health care for all, and the Fairness Project, a California organization that supports economic justice.

Both groups are active in the other states with expansion on the ballot. Well-financed, the proponents have a visible ground game and a robust television campaign.

The opposition, much less evident, is led by an anti-tax Nebraska organization called the Alliance for Taxpayers, which has filed no campaign finance documents with the state.

Marc Kaschke, former mayor of North Platte, said he is the organization’s president, but referred all questions about finances to an attorney, Gail Gitcho, who did not respond to messages left at her office.

Gitcho had previously told the Omaha World-Herald that the group hadn’t been required to file finance reports because its ads only provided information about 427; it doesn’t directly ask voters to cast ballots against the initiative.

Last week, the Alliance for Taxpayers began airing its first campaign ads. One of them complains that the expansion would give “free health care” to able-bodied adults. It features a young, healthy-looking, bearded man, slouched on a couch and eating potato chips, with crumbs spilled over his chest.

In a phone interview, Kaschke made familiar arguments against expansion. He said the state can’t afford the expansion, that it would drain money from other priorities, such as schools and roads. He said he fears the federal government would one day stop paying its share, leaving the states to pay for the whole program.

He also said, repeating Shelburn’s claim, that with limited funds, the state would be forced to cut back services to the existing population.

“We feel the states would be in a better position to solve this problem of health care,” Kaschke said. He didn’t offer suggestions on how.

Outside influence ruffles many Nebraska voters. Duane Lienemann, a retired public school agricultural teacher from Webster County near the Kansas line, said he resents outside groups coming to the state telling Nebraskans how to vote.

And he resents “liberals” from Omaha trying to shove their beliefs down the throats of those living in rural areas.

Their beliefs about expansion don’t fly with him.

“I think history will tell you when you take money away from taxpayers and give it to people as an entitlement, it is not sustainable,” Lienemann said. “You cannot grow an economy through transferring money by the government. That is socialism.”

It’s a view shared by Nebraska’s Republican governor, Pete Ricketts. He is on record opposing the expansion, repeating claims that it would force cutbacks in other government services and disputing claims, documented in expansion states, that expansion leads to job growth. But Ricketts has not made opposition to expansion a central part of his campaign.

Whether he would follow in the path of Maine’s Republican governor, Paul LePage, and seek to block implementation of the expansion if the initiative passed, is not clear. Ricketts’ office declined an interview request and did not clarify his position on blocking implementation.

For his part, Scheer, the speaker of the legislature, said he would have no part of that. “We’re elected to fulfill the wishes of the people,” he said. “If it passes, the people spoke.”

Rural Hospitals in Greater Jeopardy in the Non-Medicaid Expansion States

Michael Ollove reported that after marching 130 miles from rural Belhaven, North Carolina, to the state Capitol in Raleigh, protesters in 2015 rally against the closing of their hospital, Vidant Pungo. Medicaid expansion could be the difference between survival and extinction for many rural hospitals.

In crime novelist Agatha Christie’s biggest hit, “And Then There Were None,” guests at an island mansion die suspicious deaths one after another.

So you can forgive Jeff Lyle, a big fan of Christie’s, for comparing the 36-bed community hospital he runs in Marlin, Texas, to one of those unfortunate guests. In December, two nearby hospitals, one almost 40 miles away, the other 60 miles away, closed their doors for good.

The closings were the latest in a trend that has seen 21 rural hospitals across Texas shuttered in the past six years, leaving 160 still operating.

Lyle, who is CEO, can’t help wondering whether his Falls Community Hospital will be next.

“Most assuredly,” he replied when asked whether he could envision his central Texas hospital going under. “We’re not using our reserves yet, but I can see them from here.”

It’s not just Texas: Nearly a hundred rural hospitals in the United States have closed since 2010, according to the Center for Health Services Research at UNC-Chapel Hill. Another 600-plus rural hospitals are at risk of closing, according to an oft-cited 2016 report by iVantage Health Analytics.

Texas had the most hospitals in danger of closing (75), the health metrics firm said. And Mississippi had the largest share of hospitals at risk (79 percent).

Neither state has expanded Medicaid eligibility to more of its low-income residents under the Affordable Care Act, also known as Obamacare. In fact, the closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded.

Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure.

That is why Lyle and administrators of other rural hospitals in Texas and other non-expansion states are so adamant about their states joining the ranks of those that have expanded.

“It would mean a fair number of people we see who have no insurance would have insurance,” Lyle said. “And for us, a dollar is better than no dollar.”

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In Texas, the expansion would make 1.2 million more people eligible for Medicaid, according to a 2018 Kaiser Family Foundation analysis. An Urban Institute study in 2014 estimated that not expanding Medicaid would deprive Texas hospitals of $34.3 billion in federal reimbursements over 10 years.

Without that money, many rural hospitals in Texas and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.

By shedding those services, the hospitals diminish their reason for existing, said Maggie Elehwany, head of government affairs and policy for the National Rural Health Association.

The office of Republican Texas Gov. Greg Abbott and the most recent Republican chairmen of the health committees in the Texas legislature (the legislature has yet to make committee assignments for the current legislative session), Sen. Charles Schwertner and Rep. Four Price, did not return calls requesting comment for this story.

But not everyone believes Medicaid expansion is the answer to the problems facing rural hospitals. “Medicaid is as likely to prop up inefficient and wasteful hospitals as anything else,” said Michael Cannon, director of health policy studies at the libertarian Cato Institute.

Another rural hospital in Texas, Goodall-Witcher in Clifton, which also operates two community health clinics and a nursing room, risked closing until residents of Bosque County voted in November to create a hospital taxing district.

“I’m not saying we would have closed the day after the election,” said Adam Willmann, the hospital’s CEO, “but I don’t know how much longer we could have gone.”

The additional taxes will bring the hospital an estimated $2.5 million a year and perhaps take it out of the red, but they won’t necessarily lift Goodall-Witcher out of financial peril, Willmann said.

“Medicaid expansion,” Willmann said. “That is one of the key things we could do to help us deal with the tough financial demands we face.”

The burden of Uncompensated Care

As envisioned by the ACA when it passed Congress in 2010, expansion states would extend benefits to all adults — including childless adults — whose income was at or below 138 percent of the federal poverty line. (In 2019, that would be an average individual income of $12,140, depending on the state.)

Initially, the federal government paid 100 percent of the health care costs of the expansion population. The federal share falls to 90 percent in 2020.

To date, 36 states plus Washington, D.C., have expanded Medicaid. By 2017, expansion under the ACA had covered 17 million new enrollees. Roughly another 4 million people would qualify in the remaining states, according to a 2018 Kaiser report.

Instead, many of those low-income residents remain uninsured or underinsured in plans with high deductibles and copayments.

But that doesn’t mean people don’t receive health care. Without health insurance, low-income people are less likely to get preventive care, which often results in worsening health conditions that frequently bring them to hospitals where they are guaranteed treatment. Under federal law, hospitals must stabilize and treat anyone showing up at the emergency room, regardless of their ability to pay.

Rural hospitals, like their urban counterparts, are forced to absorb those costs. But unlike bigger hospitals, their patient volumes, and operating margins are so low that “uncompensated care” burdens can be crippling.

For instance, Willmann said his hospital’s uncompensated tab last year was about $4.2 million, or 11 to 12 percent of his overall budget.

According to the Oklahoma Hospital Association, the state’s rural hospitals carried about $170 million in bad debt from charitable care and patients’ unpaid bills. Five rural hospitals have closed in the state since 2016.

A 2018 study in the journal Health Affairs found that the rate of closures of rural hospitals increased significantly in non-expansion states after 2014 when states began implementing the expansion. At the same time, closure rates decreased in expansion states.

Many administrators of rural hospitals are quick to say that Medicaid expansion alone will not solve their financial problems. Rural hospitals faced steep challenges long before the ACA.

Rural Americans tend to be older, in poorer health and less insured than those living elsewhere, the latter resulting in a greater share of uncompensated care for rural hospitals. Because of declining populations in rural areas, hospitals there often have empty beds, which means less revenue.

“It’s been a long, slow bleed,” said Fred Blavin, a health policy expert at the Urban Institute.

Automatic federal budget cuts beginning in 2013 (known as sequestration) reduced Medicare reimbursements, which are a particularly important source of revenue for hospitals. Congress has cut back on the amount hospitals can deduct for bad debt. Congress, in its budget tightening, reduced other forms of assistance to rural hospitals as well.

“You can put a Band-Aid on, but you still have 99 other wounds,” Willmann said.

Elehwany, of the National Rural Health Association, said that rural communities where hospitals are forced to close might be able to meet residents’ health needs by opening a new urgent care facility or maternal care center.

The loss of rural hospitals not only means patients having to travel longer distances to the next medical providers, but the closures also can often have a crippling effect on the local economy.

Goodall-Witcher Hospital is the largest employer in Bosque County. “Our payroll is bigger than the county’s entire budget,” Willmann said. “Can you imagine what it would do to this county to lose $9 million from the economy a year?”

A Health Services Research journal report found that when a rural area’s only hospital closes, income per capita falls by 4 percent and unemployment rises by 1.6 percent.

Willmann was relieved voters in his district supported the measure to create a hospital taxing district, but he acknowledged that it wasn’t a good deal for his county’s taxpayers. Their federal taxes help pay for the expansion in other states but not in Texas.

“Basically, you’re asking them to pay twice,” he said.

Rural hospital officials appear not to have the slightest hope that the deep red Texas legislature and the governor will get behind expansion.

“There is no likelihood of Medicaid expansion in Texas in the near term,” said John Henderson, CEO of the Texas Organization of Rural & Community Hospitals.

The government shutdown is over, but for how long? The New York Times finally got it correct when they wrote:

‘Our Country Is Being Run by Children’: Shutdown’s End Brings Relief and Frustration

 

Five Worrisome Trends in Healthcare and the VA Seeks to Redirect Billions of Dollars into Private Care and the VA Access to Healthcare

50065252_1872612819535035_7021591760191094784_nAs the idiots in Congress still fight over the wall and continue to act like spoiled children we, the intelligent voters should be looking at healthcare delivery reality. What can we expect from these liberals and their cultural revolution? Joyce Frieden, the News Editor of MedPage Today pointed out last year that a reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.

Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:

  1. The effects of the recently passed tax bill.“If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.

Burrell noted that Medicaid, 60 million by Medicare, currently covers 74 million people and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”

  1. The increasing obesity problem.”Thirty percent of the U.S. population is obese; 70% of the total population is either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”
  2. The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”

To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”

Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue of quality but there is a profound issue on costs.”

  1. The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.
  2. The lackluster performance of new payment models.”Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.

“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, the cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect the accessibility of care.”

“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”

VA Seeks to Redirect Billions of Dollars into Private Care

Jennifer Steinhauer and Dave Phillipps reported that The Department of Veterans Affairs is preparing to shift billions of dollars from government-run veterans’ hospitals to private health care providers, setting the stage for the biggest transformation of the veterans’ medical system in a generation.

Under proposed guidelines, it would be easier for veterans to receive care in privately run hospitals and have the government pay for it. Veterans would also be allowed access to a system of proposed walk-in clinics, which would serve as a bridge between V.A. emergency rooms and private providers, and would require co-pays for treatment.

Veterans’ hospitals, which treat seven million patients annually, have struggled to see patients on time in recent years, hit by a double crush of returning Iraq and Afghanistan veterans and aging Vietnam veterans. A scandal over hidden waiting lists in 2014 sent Congress searching for fixes, and in the years since, Republicans have pushed to send veterans to the private sector, while Democrats have favored increasing the number of doctors in the V.A.

If put into effect, the proposed rules — many of whose details remain unclear as they are negotiated within the Trump administration — would be a win for the once-obscure Concerned Veterans for America, an advocacy group funded by the network founded by the billionaire industrialists Charles G. and David H. Koch, which has long championed increasing the use of private sector health care for veterans.

For individual veterans, private care could mean shorter waits, more choices and fewer requirements for co-pays — and could prove popular. But some health care experts and veterans’ groups say the change, which has no separate source of funding, would redirect money that the current veterans’ health care system — the largest in the nation — uses to provide specialty care.

Critics have also warned that switching vast numbers of veterans to private hospitals would strain care in the private sector and that costs for taxpayers could skyrocket. In addition, they say it could threaten the future of traditional veterans’ hospitals, some of which are already under review for consolidation or closing.

 President Trump, who made reforming veterans’ health care a major point of his campaign, may reveal details of the plan in his State of the Union address later this month, according to several people in the administration and others outside it who have been briefed on the plan.

The proposed changes have grown out of health care legislation, known as the Mission Act, passed by the last Congress. Supporters, who have been influential in administration policy, argue that the new rules would streamline care available to veterans, whose health problems are many but whose numbers are shrinking, and also prod the veterans’ hospital system to compete for patients, making it more efficient.

“Most veterans chose to serve their country, so they should have the choice to access care in the community with their V.A. benefits — especially if the V.A. can’t serve them in a timely and convenient manner,” said Dan Caldwell, executive director of Concerned Veterans for America.

In remarks at a joint hearing with members of the House and Senate veterans’ committees in December, Mr. Wilkie said veterans largely liked using the department’s hospitals.

“My experience is veterans are happy with the service they get at the Department of Veterans Affairs,” he said. Veterans are not “chomping at the bit” to get services elsewhere, he said, adding, “They want to go to places where people speak the language and understand the culture.”

Health care experts say that whatever the larger effects, allowing more access to private care will prove costly. A 2016 report ordered by Congress, from a panel called the Commission on Care, analyzed the cost of sending more veterans into the community for treatment and warned that unfettered access could cost well over $100 billion each year.

A fight over the future of the veterans’ health care system played a role in the ousting of the department’s previous secretary, David J. Shulkin, center.

Tricare costs have climbed steadily, and the Tricare population is younger and healthier than the general population, while Veterans Affairs patients are generally older and sicker.

Though the rules would place some restrictions on veterans, early estimates by the Office of Management and Budget found that a Tricare-style system would cost about $60 billion each year, according to a former Veterans Affairs official who worked on the project. Congress is unlikely to approve more funding, so the costs are likely to be carved out of existing funds for veterans’ hospitals.

At the same time, Tricare has been popular among recipients — so popular that the percentage of military families using it has nearly doubled since 2001, as private insurance became more expensive, according to the Harvard lecturer Linda Bilmes.

“People will naturally gravitate toward the better deal, that’s economics,” she said. “It has meant a tremendous increase in costs for the government.”

A spokesman for the Department of Veterans Affairs, Curt Cashour, declined to comment on the specifics of the new rules.

“The Mission Act, which sailed through Congress with overwhelming bipartisan support and the strong backing of veterans service organizations, gives the V.A. secretary the authority to set access standards that provide veterans the best and most timely care possible, whether at V.A. or with community providers, and the department is committed to doing just that,” he said in an email.

Veterans’ services organizations have largely opposed large-scale changes to the health program, concerned that the growing costs of outside doctors’ bills would cannibalize the veterans’ hospital system.

Dr. Shulkin, the former secretary, shared that concern. Though he said he supported increasing the use of private health care, he favored a system that would let department doctors decide when patients were sent outside for private care.

The cost of the new rules, he said, could be higher than expected, because most veterans use a mix of private insurance, Medicare and veterans’ benefits, choosing to use the benefits that offer the best deal. Many may choose to forgo Medicare, which requires a substantial co-pay if Veterans Affairs offers private care at no charge. And if enough veterans leave the veterans’ system, he said, it could collapse.

Robert L. Wilkie, the secretary of veterans’ affairs, has repeatedly said his goal is not to privatize veterans’ health care.

One of the group’s former senior advisers, Darin Selnick, played a key role in drafting the Mission Act as a veterans’ affairs adviser at the White House’s Domestic Policy Council and is now a senior adviser to the secretary of Veterans Affairs in charge of drafting the new rules. Mr. Selnick clashed with David J. Shulkin, who was the head of the V.A. for a year under Mr. Trump and is widely viewed as being instrumental in ending Mr. Shulkin’s tenure.

Mr. Selnick declined to comment.

Critics, which include nearly all of the major veterans’ organizations, say that paying for care in the private sector would starve the 153-year-old veterans’ health care system, causing many hospitals to close.

“We don’t like it,” said Rick Weidman, executive director of Vietnam Veterans of America. “This thing was initially sold as to supplement the V.A., and some people want to try and use it to supplant.”

Members of Congress from both parties have been critical of the administration’s inconsistency and lack of details in briefings. At a hearing last month, Senator John Boozman, Republican of Arkansas, told Robert L. Wilkie, the current secretary of Veterans Affairs, that his staff had sometimes come to Capitol Hill “without their act together.”

Although the Trump administration has kept details quiet, officials inside and outside the department say the plan closely resembles the military’s insurance plan, Tricare Prime, which sets a lower bar than the Department of Veterans Affairs when it comes to getting private care.

Tricare automatically allows patients to see a private doctor if they have to travel more than 30 minutes for an appointment with a military doctor, or if they have to wait more than seven days for a routine visit or 24 hours for urgent care. Under current law, veterans qualify for private care only if they have waited 30 days, and sometimes they have to travel hundreds of miles. The administration may propose for veterans a time frame somewhere between the seven- and 30-day periods.

Mr. Wilkie has repeatedly said his goal is not to privatize veterans’ health care, but would not provide details of his proposal when asked at a hearing before Congress in December.

Access to VA Health Services Now Better Than Private Hospitals?

So, the question is with the shift of funding to the privatization of VA care is access better? Nicole Lou, contributing writer for the MedPage noted that efforts to stir up access to Veterans Affairs (VA) hospitals have cut down on wait times for new patient appointments, according to a report.

In 2014, the average wait for a new VA appointment in primary care, dermatology, cardiology, or orthopedics was 22.5 days, compared with 18.7 days in private sector facilities (P=0.20). Although these wait times were statistically no different in general, there was a longer wait for an orthopedics appointment in the VA that year (23.9 days vs 9.9 days for private sector, P<0.001), noted David Shulkin, MD, former VA secretary under President Trump, and now at the University of Pennsylvania’s Leonard Davis Institute of Health Economics, and colleagues.

The study, published in JAMA Network Open, found that wait times in 2017 favored VA medical centers (17.7 days vs 29.8 days for private sector facilities, P<0.001). This was observed for primary care, dermatology, and cardiology appointments — but not orthopedics, which continued to produce appointment lags in the VA system (20.9 days vs 12.4 days, P=0.01), the authors stated.

“Although the results reflect positively on the VA, we intend to continue improving wait times, the accuracy of the data captured, and the transparency of reporting information to veterans and the public,” the researchers wrote.

Their study included VA medical centers in 15 major metropolitan areas and compared them with private sector facilities. Wait times were calculated differently based on VA records and secret shopper surveys, respectively, which was a limitation of the study, the team said.

Shulkin and colleagues found that VA wait times trended toward improvement in 11 of 15 regions, whereas private medical centers had significant increases in wait times in 12 of the 15.

Prompting the scrutiny over VA hospital wait times was a 2014 report showing that at least 40 veterans died waiting for appointments at the Phoenix VA Health Care System in Arizona. Even worse, the wait times had apparently been deliberately manipulated to look better than they were.

“This incident damaged the VA’s credibility and created a public perception regarding the VA health care system’s inability to see patients in a timely manner,” Shulkin and co-authors said. “In response, the VA has worked to improve access, including primary care, mental health, and other specialty care services.”

Meanwhile, VA medical centers continue to suffer from staffing issues such as high turnover and employee vacancies in the tens of thousands.

The study authors noted a modest increase in the number of patients going to VA hospitals for the four services studied, although that number still stayed around five million per year.

From 2014 to 2017, patient satisfaction scores also increased by 1.4%, 3.0%, and 4.0% for specialty care, routine primary care, and urgent primary care, respectively (P<0.05 for all).

Another problem with the methodology of the study was that it failed to address how easily established patients could obtain return appointments, noted an accompanying editorial by Peter Kaboli, MD, MS, of Iowa City Veterans Affairs Healthcare System, and Stephan Fihn, MD, MPH, of the University of Washington in Seattle and JAMA Network Open’s deputy editor.

Furthermore, they pointed out, a patient returning for a 6-month follow-up visit may show up in the scheduling system as having a long delay.

“As this study highlights, measuring access to healthcare remains dodgy. Even so, the seven million veterans who receive care from the VA seem able to obtain routine and urgent care in a time frame that is on par for other Americans despite increasing demand, although there are and always will be exceptions,” Kaboli and Fihn noted.

“As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to healthcare services can be maintained while access in the private sector continues to deteriorate,” they continued, adding that virtual care may be one way to improve access given the non-infinite supply of face-to-face appointments.

The VA experience seems to say that privatization of healthcare delivery is the way to go with improved access to care. So, onward to discuss universal healthcare and single payer systems of health care delivery. What would they all look like and what are the strategies to develop any of these systems.

 

 

Healthcare in 2019: Divided

 

49279916_1862477230548594_7693435305117876224_nAnd we continue with the shut down of 25% of the government. Maybe it isn’t such a bad deal for us with the waste and deficit. So, what can we anticipate for the New Year regarding healthcare? Miss Luthi reviewed that year one of a divided government in the Trump era begins with the Affordable Care Act again in legal peril. Political rhetoric around the law and healthcare generally will only intensify in the lead-up to the 2020 election cycle, but the industry is most closely watching how the administration will use executive authority to try to beat down soaring costs.

A Texas judge’s decision to overturn the ACA closed out a year where, despite congressional gridlock on healthcare, the Trump administration gained ground on systemic attempts to trim hospital payments and pharmaceutical prices, as well as reshape insurance markets. HHS Secretary Alex Azar maintains he will not bend to corporate pressure as he pushes policies like site-neutral payments and price transparency.

The policy outlook is less straightforward in Congress, where Democrats plan to use their newfound power in the House to blanket the Trump administration with oversight.

Meanwhile, Sens. Chuck Grassley (R-Iowa) and Lamar Alexander (R-Tenn.) will wrap up their legacies chairing the upper chamber’s two most influential healthcare committees—Finance and Health, Education, Labor, and Pensions, respectively. Grassley has a history of scrutinizing tax-exempt providers. And Alexander orchestrated a series of hearings in 2017 delving into the high cost of healthcare.

HHS and hospitals: It’s complicated

Hospitals want the Trump administration to more aggressively pushing executive authority to roll back red tape, particularly around the Stark law and accompanying regulations, which providers say stand in the way of some pay-for-value reforms, including building clinically integrated networks.

But hospitals have also been quick to sue over what they claim is an executive overreach, such as in the case of HHS’ sweeping cuts to the controversial 340B drug discount program. Pharmaceutical discounts through the program yield tens of millions of dollars annually for a growing number of hospitals, and it has become a territorial fight.

“This administration pushes the envelope on how far they can go with powers from Congress,” said Erik Rasmussen, a vice president at the American Hospital Association. “It’s a double-edged sword. When they go too far, we sue them.”

Hospitals sued over the government’s substantial clawback of money through a cut to 340B hospitals’ Medicare Part B drug reimbursements. Launched Jan. 1 of last year, the policy is winding its way through courts under ongoing litigation after a late-breaking 2018 win for hospitals in a federal district court. The cuts were extended to hospitals’ off-campus facilities at the beginning of this year.

Hospitals also poured lobbying dollars last year into a fight against Republican-sponsored legislation to cut back the 340B program. With a Democratic takeover of the House, hospitals are expecting a break on Capitol Hill and they plan to use the time to try to forestall political pressures over the program. Hospitals will have to disclose the community benefit funded by their 340B discount money from manufacturers, accurately estimate their discounts, and pledge to stick to the letter of the 340B law.

“We want to use the time while the field is fallow to make sure our fences are strong,” Rasmussen said. “Good fences make good neighbors.”

Hospitals and HHS anticipate a ruling on the so-called site-neutral payment policy, proposed in July and finalized in a watered-down version in November. The AHA, along with several other hospital groups, sued over the policy, again claiming executive overreach.

This administration pushes the envelope on how far they can go with powers from Congress. It’s a double-edged sword. When they go too far, we sue them.”

Under the new policy that starts this month, Medicare will pay off-site clinics the same rate it pays independent physicians for certain services.

Economist Douglas Holtz-Eakin, a former director of the Congressional Budget Office who heads the conservative American Action Forum, said it is unclear how hard the administration will ultimately come down on hospitals in light of the intense pressure.

“It has turned out to be harder than the administration expected,” Holtz-Eakin said of the payment policy. “They keep going back and forth on a policy to pay for the quality of the service, rather than paying the same rate for every site, and they’re just struggling.”

While the administration would like to keep balancing Medicare payments, he added, officials “don’t know where to go next” as they try to work out designs for these policy changes.

Hospital priorities for Congress: DSH payments

Congress has a hard deadline of Sept. 30 to decide how to manage the scheduled disproportionate-share hospital payment cuts, passed with the ACA, but never implemented.

Lawmakers last year authorized a one-year-only delay to billions of dollars in cuts to these payments, teeing up a potential legislative overhaul of the program in 2019. Republican Sen. Marco Rubio of Florida, one of the states least favored under the current formulas, has already introduced a proposal to start negotiations.

Hospital lobbyists, eager to protect overall DSH funding, have signaled lawmakers could modify the law, which has largely remained untouched since 1992.

“The devil’s in the details,” said Carlos Jackson of America’s Essential Hospitals—a trade group for hospitals that benefit significantly from the program. “We are happy to have conversations about changes, but the details matter.”

Jackson also questioned whether lawmakers in this supercharged political environment would be able to dive into real policy changes by September.

“Will they have the time?” he asked.

A small number of states—Alabama, Missouri, New Jersey, and New York—benefit more than others from DSH. Financially, the payments are a very big deal for hospitals with high numbers of Medicaid patients, such as major university medical centers.

Here, too, ongoing litigation is a complicating factor. Hospitals have challenged an Obama-era rule requiring them to deduct any Medicare or commercial insurance reimbursements from their total DSH allotment.

Hospitals also want the Democratic House to pick up where Republicans left off on a “Red Tape Relief” project targeting Medicare regulations that hospitals say cost them billions a year in extra work and unnecessary or redundant expenses.

Democrats haven’t decided what they will do, but lobbyists think House Republicans may be able to work with the Trump administration on policy work that could gain bipartisan support.

“It’s been a while since we’ve had a GOP minority in the House with a Republican president,” the AHA’s Rasmussen said. “Republicans in the House will still be important because they can work on the administration on this sort of thing.”

Tax-exempt hospitals are also bracing for the spotlight. Grassley—who for years has been investigating whether hospitals with not-for-profit status are producing enough justifying community benefit—is retiring in two years. Former and current aides said his scrutiny of hospitals with massive tax benefits will continue. Throughout this year, he has kept up communication with the IRS on how the agency monitors the activity of not-for-profit hospitals.

Pharmaceuticals: ‘It’ll be busy’

If hospitals are wary about mixed financial prospects in 2019, the pharmaceutical industry is preparing for full-on political war.

Manufacturers lost a key lobbying battle in 2018 when they tried to recoup billions of dollars from the money Congress appropriated through the Medicare Part D coverage gap known as the “donut hole.”

This year will bring much more: the specifics of a proposal to control U.S. drug prices by tying them to an international price index; step therapy in Medicare Part B; and the authority for Medicare Part D insurers to exclude some protected-class drugs that are currently off limits.

If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere.”

Said James Greenwood, President, and CEO of Biotechnology Innovation Organization.

“We face all of that, and then there’s the change in the majority of the House,” said James Greenwood, CEO of the Biotechnology Innovation Organization trade group. “Democrats have run very hard on the issue of drug pricing and investigation.”

There’s also Grassley, who has long been zealous on Big Pharma oversight.

“It’ll be busy,” Greenwood said.

He said he is focused on messaging and public perception of manufacturers who, he said “shoulder 95% of the rhetoric” for skyrocketing healthcare costs.

“If the issue is that we need to protect Medicare, I’m all in as long as Congress looks at where the real money is: hospitals and elsewhere,” Greenwood said.

Manufacturers are also looking to the administration’s use of executive authority for some wins, specifically on 340B where they clash most intensely with hospitals.

“There’s a lot the administration can do,” Greenwood said. “The powers they are using with the other proposals, like (the CMS Innovation Center), they can apply to the 340B program.”

Insurers: Focus on the individual market

Obamacare’s individual market premiums have stabilized but at a high price. And as Democratic progressives push a single-payer approach in the lead-up to the 2020 presidential election, insurers want to make sure the individual market can attract people who have ditched or so far avoided the exchanges because of cost.

Justine Handelman of the Blue Cross and Blue Shield Association wants Congress to try again on reinsurance funding and to look at the expansion of the tax credit subsidy, particularly to draw younger people into the exchanges.

Given the breakdown of bipartisan talks to fund reinsurance and cost-sharing reduction payments in 2018, it’s unlikely the Democratic proposal to further subsidize the exchanges will go anywhere with the Trump administration and Republican Senate.

‘Medicare for all’? This we will discuss more in the next few weeks.

Key to watch as the year unfolds is what the fallout of the ACA litigation—panned by most legal analysts but also possibly headed to the Supreme Court—will herald for both parties for healthcare ahead of 2020 when progressive Democrats want their party to embrace “Medicare for all.”

Sen. Elizabeth Warren of Massachusetts, the first Democrat to jump into the presidential race, has already made the policy part of her platform.

Progressive Democratic Reps. Ro Khanna of California and Pramila Jayapal of Washington state, who are leading the way on a new “Medicare for all” draft, plan to push a floor vote on the legislation. They told Modern Healthcare they will introduce the new version once the 676 bill number is available—a nod to the original House legislation from former Rep. John Conyers (D-Mich.).

Dems hit GOP on health care with additional ObamaCare lawsuit vote

As Jessie Hellmann noted The House on Wednesday passed a resolution backing the chamber’s recent move to defend ObamaCare against a lawsuit filed by GOP states, giving Democrats another opportunity to hit Republicans on health care.

GOP Reps. Brian Fitzpatrick (Pa.), John Katko (N.Y.) and Tom Reed (N.Y.) joined with 232 Democrats to support the measure, part of Democrats’ strategy of keeping the focus on the health care law heading into 2020. The final vote tally was 235-192.

While the House voted on Friday to formally intervene in the lawsuit as part of a larger rules package, Democrats teed up Wednesday’s resolution as a standalone measure designed to put Republicans on record with their opposition to the 2010 law.

A federal judge in Texas last month ruled in favor of the GOP-led lawsuit, saying ObamaCare as a whole is invalid. The ruling, however, will not take effect while it is appealed.

Democrats framed Wednesday’s vote as proof that Republicans don’t want to safeguard protections for people with pre-existing conditions — one of the law’s most popular provisions.

“If you support coverage for pre-existing conditions, you will support this measure to try to protect it. It’s that simple,” said Rules Committee Chairman Jim McGovern (D-Mass.) before the vote.

Most Republicans opposed the resolution, arguing it was unnecessary since the House voted last week to file the motion to intervene.

“At best, this proposal is a political exercise intended to allow the majority to reiterate their position on the Affordable Care Act,” said Rep.Tom Cole (R-Okla.). “At worst, it’s an attempt to pressure the courts, but either way, there’s no real justification for doing what the majority wishes to do today.”

The Democratic-led states defending the law are going through the process of appealing a federal judge’s decision that ObamaCare is unconstitutional because it can’t stand without the individual mandate, which Congress repealed.

Democrats were laser-focused on health care and protections for people with pre-existing conditions during the midterm elections — issues they credit with helping them win back the House.

The Trump administration has declined to defend ObamaCare in the lawsuit filed by Republican-led states, which argue that the law’s protections for people with pre-existing conditions should be overturned. It’s unusual for the DOJ to not defend standing federal law.

The House Judiciary Committee, under the new leadership of Chairman Jerrold Nadler (D-N.Y.), plans to investigate why the Department of Justice decided not to defend ObamaCare in the lawsuit.

“The judiciary committee will be investigating how the administration made this blatantly political decision and hold those responsible accountable for their actions,” Nadler said.

Democrats are also putting together proposals to undo what they describe as the Trump administration’s efforts to “sabotage” the law and depress enrollment.

“We’re determined to get that case overruled, and also determined to make sure the Affordable Care Act is stabilized so that the sabotage the Trump administration is trying to inflict ends,” said Rep. Frank Pallone Jr. (D-N.J.), chairman of the Energy and Commerce Committee, which has jurisdiction over ObamaCare.

One of the committee’s first hearings this year will focus on the impacts of the lawsuit. The hearing is expected to take place this month.

The Ways and Means Committee, under the leadership of Chairman Richard Neal (D-Mass), will also hold hearings on the lawsuit and on protections for people with pre-existing conditions.

Those two committees, along with the Education and Labor Committee, are working on legislation that would shore up ObamaCare by increasing eligibility for subsidies, blocking non-ObamaCare plans expanded by the administration and increasing outreach for open enrollment.

GOP seeks health care reboot after 2018 losses

Alexander Bolton reviewed the future strategies of the GOP. He noted that the Republicans are looking for a new message and platform to replace their longtime call to repeal and replace ObamaCare after efforts failed in the last Congress and left them empty-handed in the 2018 midterm elections.

Republican strategists concede that Democrats dominated the health care debate heading into Election Day, helping them pick up 40 seats in the House.

President Trump hammered away on immigration in the fall campaign, which helped Senate Republican candidates win in conservative states but proved less effective in suburban swing areas, which will be crucial in the 2020 election.

While Trump is focused on raising the profile of illegal immigration during a standoff over the border wall, other Republicans are quietly looking for a better strategy on health care, which is usually a top polling issue.

“Health care is such a significant part of our economy and the challenges are growing so great with the retirement of the baby boomers and the disruption brought about by ObamaCare that you can’t just cede a critically important issue to the other side,” said Whit Ayres, a Republican pollster.

“Republicans need a positive vision about what should happen to lower costs, expand access and protect pre-existing conditions,” he added. “You’ve got to be able to answer the question, ‘So what do you think we should do about health care?’ ”

A recent Associated Press-NORC Center for Public Affairs Research poll showed that 49 percent of respondents nationwide said the government should tackle health care as a top priority, second only to economic concerns.

During his 2016 presidential campaign, Trump vowed to lower prescription drug costs, but the Republican-controlled Congress over the past couple of years focused on other matters. House Democrats who are now in the majority say they are willing to work with the White House on drug pricing, but it’s unclear if Republicans will take on the powerful pharmaceutical industry, long considered a GOP ally.

Republican candidates made the repeal of ObamaCare their main message in 2010, 2012, 2014 and 2016 elections. But after repeal legislation collapsed with the late Sen.John McCain’s (R-Ariz.) famous “no” vote, the party’s message became muddled and Democrats went on the offensive.

Some Republicans continued to work on alternative legislation, such as a Medicaid block grant bill sponsored by Sens. Lindsey Graham(S.C.) and Bill Cassidy(La.), but it failed to gain much traction and the GOP health care message was left in limbo.

“We should be the guys and gals that are putting up things that make health care more affordable and more accessible,” said Jim McLaughlin, another Republican pollster. “No question Democrats had an advantage over us on health care, which they never should have had because they’re the ones that gave us the unpopular ObamaCare.”

“We need to take it to the next level,” he added. “You can’t get [ObamaCare] repealed. Let’s do things that will make health care more affordable and more accessible.”

Senate Health Committee Chairman Lamar Alexander (R-Tenn.), a close ally of Senate Majority Leader Mitch McConnell(R-Ky.), says finding an answer to that question will be his top priority in the weeks ahead.

Alexander will be meeting soon with Sen. Patty Murray(Wash.), the top Democrat on the Health Committee, as well as Sens. Chuck Grassley(R-Iowa) and Ron Wyden(D-Ore.), the leaders of the Senate Finance Committee, to explore solutions for lowering health care costs.

“I’ll be meeting with senators on reducing health care costs,” Alexander told The Hill in a recent interview. “At a time when one-half of our health care spending is unnecessary, according to the experts, we ought to be able to agree in a bipartisan way to reduce that.”

He recently announced his retirement from the Senate at the end of 2020, freeing him to devote his time to the complex and politically challenging issue of health care reform without overhanging reelection concerns.

Alexander sent a letter to the center-right leaning American Enterprise Institute and the center-left leaning Brookings Institution last month requesting recommendations by March 1 for lowering health care costs.

In Dec. 11 floor speech, Alexander signaled that Republicans want to move away from the acrimonious question of how to help people who don’t have employer-provided health insurance, a question that dominated the ObamaCare debate of the past decade, and focus instead on how to make treatment more affordable.

He noted that experts who testified before the Senate in the second half of last year estimated that 30 to 50 percent of all health care spending is unnecessary.

“The truth is we will never have lower cost health insurance until we have lower cost health care,” Alexander said on the floor. “Instead of continuing to argue over a small part of the insurance market, what we should be discussing is the high cost of health care that affects every American.”

A Senate Republican aide said GOP lawmakers are prepared to abandon the battle over the best way to regulate health insurance and focus instead on costs, which they now see as a more fundamental issue.

“There’s no point in trying to talk about health insurance anymore. Fundamentally, insurance won’t be affordable until we make health care affordable, so we have to do stuff to reduce health care costs,” said the aide.

“There are lots of things that can be done to reduce health care costs that aren’t insurance, that aren’t necessarily partisan,” the source added.

“We’re looking at ideas that aren’t necessarily partisan and don’t advance the cause of single-payer health care and don’t advance the cause of ‘only the market’ but are about addressing these drivers of health care cost and try to change the trajectory.”

Another key player is Cassidy, a physician, and member of the Health and Finance committees, who has co-sponsored at least seven bills to improve access and lower costs.

One measure Cassidy backed is co-sponsored by Sen. Tina Smith(D-Minn.) and would develop innovative ways to reduce unnecessary administrative costs.

Another measure Cassidy co-sponsored with Sens. Maria Cantwell (D-Wash.) and Tom Carper (D-Del.) would allow individuals to pay for primary-care service from a health savings account and allow taxpayers enrolled in high-deductible health plans to take a tax deduction for payments to such savings accounts.

He is also working on a draft bill to prohibit the surprise medical billing of patients.

McConnell signaled after Democrats won control of the House in November that the GOP would abandon its partisan approach to health care reform and concentrate instead on bipartisan proposals to address mounting costs, which Democratic candidates capitalized on in the fall campaign.

Asked about whether the GOP would stick with its mission to repeal ObamaCare, McConnell said: “it’s pretty obvious the Democratic House is not going to be interested in that.”

Half the 600,000 residents aided by NYC Care are undocumented immigrants

As John Bacon of USA Today reported the comprehensive health care plan unveiled by New York City Mayor Bill de Blasio this week drew applause from the Democrat’s supporters but also skepticism from those in the city who question the value and cost of the effort.

De Blasio said NYC Care will provide primary and specialty care from pediatric to geriatric to 600,000 uninsured New Yorkers. De Blasio estimated the annual cost at $100 million.

“This is the city paying for direct comprehensive care (not just ERs) for people who can’t afford it, or can’t get comprehensive Medicaid – including 300,000 undocumented New Yorkers,” Eric Phillips, spokesman for de Blasio, boasted on Twitter.

State Assemblywoman Nicole Malliotakis, a Republican representing parts of Brooklyn and Staten Island, criticized the proposal as an example of de Blasio using city coffers “like his personal ATM.”

“How about instead of giving free health care to 300,000 citizens of other countries, you lower property taxes for our senior citizens who are being forced to sell the homes they’ve lived in for decades because they can’t afford to pay your 44 percent increase in property taxes?” she said.

Seth Barron, associate editor of City Journal and project director of the NYC Initiative at the Manhattan Institute think tank, noted that the city’s uninsured, including undocumented residents, can receive treatment on demand at city hospitals. The city pays more than $8 billion to treat 1.1 million people through its New York City Health + Hospitals program, he wrote.

Barron said the mayor is simply trying to shift patients away from the emergency room and into clinics. He said that dividing $100 million by 600,000 people comes to about $170 per person, the equivalent of one doctor visit.

“Clearly, the money that the mayor is assigning to this new initiative is intended for outreach, to convince people to go to the city’s already-burdened public clinics instead of waiting until they get sick enough to need an emergency room,” Barron wrote. “That’s fine, as far as it goes, but as a transformative, revolutionary program, it resembles telling people to call the Housing Authority if they need an apartment and then pretending that the housing crisis has been solved.”

The plan expands upon the city’s MetroPlus public option plan, as well as the state’s exchange through the federal Affordable Care Act. NYC Care patients will be issued cards allowing them access to medical services, de Blasio said.

The mayor’s plan has plenty of support. Mitchell Katz, president, and CEO of NYC Health + Hospitals said the plan will help his agency “give all New Yorkers the quality care they deserve.” State Sen. James Sanders Jr., who represents parts of Queens, said he looks forward “to seeing the Care NYC program grow and prosper as it helps to create a healthier New York.”

The drumbeat for improved access to health care is not limited to New York.

California Gov. Gavin Newsom on Monday asked Congress and the White House to empower states to develop “a single-payer health system to achieve universal coverage, contain costs and promote quality and affordability.”

Washington Gov. Jay Inslee on Tuesday proposed Cascade Care, a public option plan under his state’s health insurance exchange.

“We’re going to do all we can to protect health care for Washingtonians,” he said. “This public option will ensure consumers in every part of the state will have an option for high-quality, affordable coverage.”

Newsom pushes sweeping new California health-care plan to help illegal immigrants, prop up ObamaCare

Greg Re noted that shortly after he took office on Monday, California’s Democratic Gov. Gavin Newsom unearthed an unprecedented new health care agenda for his state, aimed at offering dramatically more benefits to illegal immigrants and protecting the embattled Affordable Care Act, which a federal judge recently struck down as unconstitutional.

The sweeping proposal appeared destined to push California — already one of the nation’s most liberal states — even further to the left, as progressive Democrats there won a veto-proof supermajority in the state legislature in November and control all statewide offices.

“People’s lives, freedom, security, the water we drink, the air we breathe — they all hang in the balance,” Newsom, 51, told supporters Monday in a tent outside the state Capitol building, as he discussed his plans to address issues from homelessness to criminal justice and the environment. “The country is watching us, the world is watching us. The future depends on us, and we will seize this moment.”

Newsom unveiled his new health-care plan hours after a protester interrupted his swearing-in ceremony to protest the murder of police Cpl. Ronil Singh shortly after Christmas Day. The suspect in Singh’s killing is an illegal immigrant with several prior arrests, and Republicans have charged that so-called “sanctuary state” policies, like the ones Newsom has championed, contributed to the murder by prohibiting state police from cooperating with federal immigration officials.

As one of his first orders of business, Newsom — who also on Monday requested that the Trump administration cooperates in the state’s efforts to convert to a single-payer system, even as he bashed the White House as corrupt and immoral — declared his intent to reinstate the ObamaCare individual mandate at the state level.

ANALYSIS: AS CALIFORNIA’S PROGRESSIVE POLICIES GET CRAZIER, WHAT’S THE SILVER LINING FOR THE GOP?

The mandate forces individuals to purchase health care coverage or pay a fee that the Supreme Court described in 2012 as a “tax,” rather than a “penalty” that would have run afoul of Congress’ authority under the Commerce Clause of the Constitution. Last month, though, a federal judge in Texas ruled the individual mandate no longer was a constitutional exercise of Congress’ taxing power because Republicans had passed legislation eliminating the tax entirely — a move, the judge said, that rendered the entire health-care law unworkable.

As that ruling works its way to what analysts say will be an inevitable Supreme Court showdown, Newsom said he would reimpose it in order to subsidize state health care.

Medi-Cal, the state’s health insurance program, now will let illegal immigrants remain on the rolls until they are 26, according to Newsom’s new agenda. The previous age cutoff was 19, as The Sacramento Bee reported.

Additionally, Newsom announced he would sign an executive order dramatically expanding the state’s Department of Health Care Services authority to negotiate drug prices, in the hopes of lowering prescription drug costs.

In his inaugural remarks, Newsom hinted that he intended to abandon the relative fiscal restraint that marked the most recent tenure of his predecessor, Jerry Brown, from 2011 to 2019. Brown sometimes rebuked progressive efforts to spend big on various social programs.

“For eight years, California has built a foundation of rock,” Newsom said. “Our job now is not to rest on that foundation. It is to build our house upon it.”

Newsom added that California will not have “one house for the rich and one for the poor, or one for the native-born and one for the rest.”

“The country is watching us, the world is watching us.”

In a statement, the California Immigrant Policy Center backed Newsom’s agenda.

“Making sure healthcare is affordable and accessible for every Californian, including undocumented community members whom the federal government has unjustly shut out of care, is essential to reaching that vision for our future,” the organization said. “Today’s announcement is a historic step on the road toward health justice for all.”

The Sacramento Bee reported on several of Newsom’s recent hires, which seemingly signaled he’s serious about his push to bring universal health care to California. Chief of Staff Ann O’Leary worked in former President Bill Clinton’s administration on the Children’s Health Insurance Program (CHIP), which offers affordable health care to children in families who exceed the financial threshold to qualify for Medicaid, but who are too poor to buy private insurance.

And, Cabinet Secretary Ana Matosantos, who worked in the administrations of Brown and former GOP Gov. Arnold Schwarzenegger, has worked extensively to implement ObamaCare in California and also worked with the legislature to expand health-care coverage for low-income Californians.

 This next year should be an exciting time if Congress and the President can figure out how to get along and how to work together to improve health care. I believe that if neither the President nor the Dems come together to solve this wall, fence, or monies for better illegal immigrant deterrents nothing will happen in healthcare and probably nothing will happen on any level. What a bunch of spoiled children!!

Onward!!!

‘Medicare for all’ proposal headed for House hearings and More States Expanding Medicaid

 

 

49025855_1851541661642151_2035183627737759744_nFirst, as we all are frustrated because of the government shutdown, most Federal Health Agencies are OK despite the shutdown. The FDA is feeling the pinch; IHS, ATSDR are affected also. However, it does point out the problems that Congress will face in the next 2 or more years because of political differences and the lack of civility.

News Editor Joyce Frieden pointed out that the partial shutdown of the federal government doesn’t appear to have had an immediate effect on most healthcare-related agencies, but observers expressed concern over what the shutdown might mean for the long term.

The Department of Health and Human Services (HHS), obviously the largest healthcare-related agency, has been largely unaffected by the shutdown, which began at 12:01 a.m. December 22, since most of the department is already funded through fiscal year 2019. However, the FDA is affected because its appropriations fall under a different authorization bill than the rest of HHS, so the agency had to furlough 7,053 staff members; the remaining 10,344 staff members were retained, either because they were performing functions critical to public health and safety, such as protecting ongoing experiments, or because their programs — such as tobacco regulation or new drug development — are funded by user fees.

The Alliance for a Stronger FDA — a group of patient organizations, trade associations, and pharmaceutical and biomedical companies that support adequate funding for the agency — expressed some concerns about the shutdown. “The FDA regulates products that make up 20% of consumer spending,” the organization said in a statement. “The agency’s responsibilities cannot be fully met when 7,000 employees are furloughed. Further, when the FDA is not fulfilling its critical public health responsibilities, there is no backstop to the agency’s work.”

However, “having said that, we have confidence that [FDA Commissioner] Dr. [Scott] Gottlieb and FDA leadership have ensured the emergency and critical public health and safety functions will be covered during a shutdown,” the statement continued. “Consumers should not panic — the FDA is still on the job. The immediate problem, quite a serious one, is the slowing of work on longer-term priorities and items that aren’t absolutely essential. Managing only those items that could turn into an immediate crisis is no way to run an agency that is critical to public health.”

The shutdown also hits the Indian Health Service (IHS), although direct patient care is not affected, HHS explained in its FY 2019 Contingency Staffing Plan, which was issued before the shutdown actually began. In the event of a shutdown, “IHS would continue to provide direct clinical health care services as well as referrals for contracted services that cannot be provided through IHS clinics,” the document noted. As for other IHS services, “many administrative activities are impacted due to the lapse in funding for the IHS,” a spokeswoman said in an email to MedPage Today.

Asked for examples of administrative services that IHS would continue to perform, the spokeswoman said, “The IHS can only perform administrative, oversight, and other functions that are necessary to meet the immediate needs of its patients, medical staff, and medical facilities.” Other media are reporting that some tribes will need to furlough staff and cut back services at their tribally run health clinics if the shutdown continues.

The National Institutes of Health (NIH) is largely unaffected by the shutdown except for the National Institute of Environmental Health Sciences, based in Research Triangle Park, North Carolina. There, Superfund Research Program staff are furloughed and oversight work dealing with about 50 grants is suspended, according to the staffing plan. An NIH spokeswoman confirmed in an email that no other NIH divisions have been affected.

The Agency for Toxic Substances and Disease Registry in Atlanta is another HHS division affected by the shutdown. Although the agency, which deals with environmental health threats and emergencies, will continue carrying out emergency-related functions, it cannot “support most environmental health professional training programs, continuous updating of health exposure assessments and recommendations, and technical assistance, analysis, and [provide] other support to state and local partners,” the staffing plan noted.

Susannah Luthi noted that a new single-payer health system concept will have a set of congressional hearings in the new Democratic House, and a new draft of a so-called “Medicare for all” proposal could be released as soon as next week.

Washington state progressive Democratic Rep. Pramila Jayapal, who over the summer launched the Medicare for All Caucus, said the hearings, with the support of House Speaker Nancy Pelosi (D-Calif.), will start in the House Rules and Budget committees before moving on to the House Energy and Commerce Committee.

“My goal is that these are opportunities to make the case not to the American people—the American people already had the case made to them—but to members of Congress, to really put forward what the legislation looks like,” Jayapal said Thursday after the new Congress elected Pelosi to the speakership.

Pelosi spokesperson Henry Connelly confirmed the speaker supports holding the hearings, although Jayapal acknowledged House Energy and Commerce Chair Frank Pallone (D-N.J.) hasn’t yet committed his panel.

“But I have the speaker’s commitment that she will help me do this, and I’ve spoken to Frank Pallone and he is not opposed,” Jayapal said. “He just hasn’t said ‘yes’ yet.”

A Pallone spokesperson did not respond to a request for comment by deadline.

Jayapal has not yet discussed possible hearings with the head of the other key health panel, Chair Richard Neal (D-Mass.) of the House Ways and Means Committee, but Neal said he is open to discussing the policy as one of the “many options that are out there” as part of holding his committee to regular order.

“That’s what committees are supposed to do, to flesh out alternatives,” Neal said.

This will be the first House hearing since the Affordable Care Act debate when the health panel of the House Committee on Education and Workforce looked at the option.

Details of the bill, a draft of which Jayapal said should be available in the next couple of weeks, are under wraps but she said it does vary from the legislation introduced by Sen. Bernie Sanders (I-Vt.) in 2017. Sanders catapulted talk of “Medicare for all” to the fore during his 2016 presidential bid and key Democratic senators has signed on to his policy since.

This is a different bill, Jayapal said. It’s largely the work of her staff and the staff of Rep. Debbie Dingell (D-Mich.), who sits on the Energy and Commerce Committee.

This new momentum for single payer—an issue that sharply divides the party—comes as Democrats are focused on defending Obamacare and as insurers hold out hope for more funding to shore up the law and draw more people into the individual market.

House Democrats will formally intervene in the lawsuit to overturn the Affordable Care Act following a Texas federal judge’s invalidation of the law—largely a political move around litigation that proved to help the Democrats in November’s elections.

In his first hearing announcement of the new Congress on Thursday, Pallone said his panel will focus on the lawsuit and its impacts. “This decision, if it is upheld, will endanger the lives of millions of Americans who could lose their health coverage,” the release from the Energy and Commerce Committee said. “It would also allow insurance companies to once again discriminate against more than 133 million Americans with pre-existing conditions.”

Judge Reed O’Connor, the Texas judge presiding over the case, ordered that the law is to remain in place as the lawsuit winds its way through the courts on appeal. It is headed next to the Fifth U.S. Circuit Court of Appeals in Louisiana.

The lawsuit was a political winner for Democrats in their campaign to reclaim the House in November, denouncing the GOP state attorneys general who filed the lawsuit and the Trump administration, which sided with the plaintiffs and refused to defend the ACA.

New Maine governor orders Medicaid expansion

Harris Meyer pointed out that the new Democratic Gov. Janet Mills signed an executive order Thursday implementing Maine’s Medicaid expansion, which was overwhelmingly approved by the state’s voters in 2017.The previous governor, Republican Paul LePage, had strongly resisted the expansion, resulting in a court battle that dragged through most of last year and ended with a judge ordering him to move forward with the Medicaid changes. In previous years, he vetoed five bills passed by the legislature to expand the program. An estimated 70,000 low-income adults will be eligible for Medicaid coverage under the expansion. Maine will become the 33rd state to extend the program under the Affordable Care Act to people with incomes up to 138% of the federal poverty level. Voters in Idaho, Nebraska and Utah approved similar Medicaid expansions.

‘Medicare for all’ advocates emboldened by ObamaCare lawsuit

Nathaniel Weixel looked at the ObamaCare lawsuit and its relationship to Medicare for All. Progressive groups and lawmakers plan to use a Texas judge’s ruling against ObamaCare to jump-start their push for “Medicare for all” in the next Congress.

Supporters of a single-payer health system are arguing that now is the time to start moving in a new direction from the Affordable Care Act, in part because they feel the 2010 health law will never be safe from Republican attempts to destroy or sabotage it.

“In light of the Republican Party’s assault, a version of Medicare for all is necessary for the future,” said Topher Spiro, vice president for health policy at the Center for American Progress. “There are just too many points of vulnerability in the current system.”

The court decision in Texas that invalidates ObamaCare in its entirety came on the heels of sweeping Democratic victories in the midterm elections, a combination that has energized advocates of Medicare for all.

“We need to do everything we can to ensure every single American has access to affordable, quality healthcare. Medicare for all has the potential to do just that as it can reduce the complexity and cost with a single payer health care system,” Rep. Debbie Dingell (D-Mich.), co-chair of the Medicare for All Caucus, said in a statement to The Hill.

Yet the effort could very well create divisions within the Democratic Party, as leaders who want to protect and strengthen the health law are reluctant to completely embrace government-run universal health insurance.

In the House and Senate, leading Democrats have said their priorities should be strengthening ObamaCare, rather than fighting over single-payer.

The lawsuit in Texas is almost certain to be overturned, they argue, and their time is better spent making sure people with pre-existing conditions remain free from discrimination by insurers.

“I think the ruling gets overturned within a couple months, so I’m not sure it matters in the long-term fight over the next generation of health-care reform,” said Sen. Chris Murphy(D-Conn.).

Sen. Ron Wyden (D-Ore.) said Democrats should focus on making sure the insurance landscape doesn’t revert to what it was before ObamaCare.

“The first thing we have to do is make sure people don’t lose what they have today — the pre-existing conditions protections — and going back to the days when there was health care for the healthy and the wealthy,” he said.

U.S. District Court Judge Reed O’Connor this month struck down the Affordable Care Act, throwing a new round of uncertainty into the fate of the law.

O’Connor ruled that the law’s individual mandate is unconstitutional, and that because the mandate cannot be separated from the rest of the law, the rest of the law is also invalid.

The court case, brought by 20 GOP-led states, was at the center of this year’s midterm campaign after Democrats attacked Republicans for supporting the lawsuit and seeking to overturn ObamaCare’s protections for pre-existing conditions.

The Trump administration, in a rare move, declined to defend the law in court, arguing instead that the pre-existing condition protections should be overturned.

“This is an outrageous, disastrous decision that threatens the health care and lives of millions of people. It must be overturned,” Sen. Bernie Sanders (I-Vt.) tweeted shortly after the decision was published. “We must move forward to make health care a right for every American.”

Rep. Ro Khanna (D-Calif.), who will be vice chairman of the House Progressive Caucus next year, said the decision “absolutely” makes a case for Medicare for all.

“There’s no doubt that would be constitutional. Medicare is already constitutional and what we’re saying is extend it to everyone, so there can be no constitutional argument,” Khanna told The Hill.

Eagan Kemp, a health-care expert with the advocacy group Public Citizen, also noted how uncontroversial Medicare is compared to ObamaCare.

“This is one more example of how tenuous the law really is,” Kemp said. “You don’t see the same type of sabotage to Medicare. So to me it highlights that the Medicare program remains the third rail of politics, so if we’re going to build a new health-care system, it’s something that can be safe.”

Some lawmakers said they understand the need to be pragmatic since centrist Democrats might not take the same message from the Texas ruling as progressives.

Khanna said he doesn’t think protecting ObamaCare from Republican attacks has to be a separate endeavor from Medicare for all.

Rep. Jan Schakowsky (D-Ill.), a member of the Medicare for All Caucus, told The Hill the fallout from the lawsuit “may help us move in an even more bold and aggressive agenda” on health care.

“We’ll see, though. I think this is the kind of issue that needs a broad consensus, may need some more outreach to the public,” Schakowsky said. “But I am interested in pursuing that agenda.”

Judge grants stay after ruling Affordable Care Act unconstitutional, Obamacare stays in effect

William Cummings of USA Today, reviewed the latest wrinkle in the Obamacare sage,  a federal judge on Sunday said his decision declaring the Affordable Care Act unconstitutional will not take effect while the appeals of his ruling move through the courts.

U.S. District Judge Reed O’Connor wrote in a 30-page court filing that while he believes the Fifth Circuit Court of Appeals “is unlikely to disagree” with his ruling, he agreed to stay his decision because “many everyday Americans would otherwise face great uncertainty” while the appeals play out.

On Dec. 14, O’Connor sided with a coalition of conservative states in a lawsuit challenging the constitutionality of former President Barack Obama’s signature health care law. He found that the individual mandate requiring people to buy health insurance was unconstitutional and said that meant the rest of the law was invalid as well.

In 2012, the Supreme Court upheld the law on the grounds that mandate fell within Congress’ taxation powers. When Congress removed the tax penalty for not buying insurance, that constitutional foundation was knocked out, O’Connor reasoned.

The Trump administration announced in June that it would not defend the individual mandate and other provisions of the law – such as protections for people with pre-existing conditions. But the Justice Department argued those provisions of the law could be thrown out without striking down the entire. O’Connor disagreed.

A group of Democratic states and congressional Democrats have said they plan to appeal O’Connor’s decision, which will next head to the Fifth Circuit. Although O’Connor did not grant an injunction blocking Obamacare in his initial ruling, the coalition led by California asked the judge on Dec. 17 to issue a stay and make it clear that the law will stay in place pending the appeal.

Many experts expect that appellate court to disagree with O’Connor’s ruling that the individual mandate can’t be separated from the rest of the law. If O’Connor’s ruling is upheld it is expected that the case would head to the Supreme Court.

Calif. Medical Assn. President Shares Medical Horror Story

Cheryl Clark, a contributing writer for MedPage Today wrote that the new president of the California Medical Association was expecting to spend New Year’s at a wedding in Las Vegas.

Instead, David Aizuss, MD, posted on Facebook about his “eye opening” first-hand view of “American medicine at its worst.” (The post is visible only to his Facebook friends and he declined MedPage Today‘s request to elaborate, citing ongoing “medical issues.”)

In his post, Aizuss said he was rushed by ambulance to a hospital Monday morning. “I spent hours in the emergency room where I received inadequate treatment of mind boggling pain, was never touched or examined by a physician, was mixed up with another patient and almost inadvertently transferred to another hospital, (and) was scheduled for emergency surgery based on a third patient’s lab work that was confused with mine,” he wrote.

He “finally signed out of the hospital against medical advice so I could obtain care from physicians that I know and trust.” He did not name the hospital.

Aizuss, an ophthalmologist who practices in Calabasas, northwest of Los Angeles, posted his complaint New Year’s Eve, apparently while at the LAX International airport in Los Angeles, where he said he was “just returning from Las Vegas where we were supposed to attend a wedding.”

Dozens of Facebook friends, several apparently also physicians, expressed their shock that the CMA president could receive such poor emergency room response, and some said they were happy he was speaking out about poor quality of hospital care.

“If you get terrible care like this (at least you know the difference) think about the care that Joe Sixpack gets; he doesn’t have the resources to get better care. This system is broken and we need to fix it,” posted one.

Wrote another, “As president of the CMA, your voice can be loud! Don’t be timid and do not be afraid of making enemies. Remember our patients know and respect us when we stand against poor medicine.”

Aizuss ended the post by saying, “Truly an eye-opening experience for the President of the California Medical Association. Happy New Year to all!”

He began his one-year term as CMA president in mid-October, saying he wanted to focus on physician burnout, practice sustainability, and payment. He is also past chairman of the CMA Board of Trustees.

He is a medical staff member at Tarzana Hospital and West Hills Hospital, in Los Angeles County, and serves as an assistant clinical professor of ophthalmology at the UCLA Geffen School of Medicine.

The CMA represents about 43,000 physicians in the state and is the second largest organized medicine group of any state, next to the Texas Medical Association, which represents about 52,000 physicians.

Why did I end with this article? It points out the fact that whatever the politics, we all have to continue to forge a better health care system. We need to get rid of the biases and the politics and strive, no demand a better healthcare delivery system. But we also have to realize that it will take some radicle changes, but it will be worth it in the end.

Let us continue the research and discussion  into what the healthcare system will look like in our future!

Healthcare in 2018. Let’s Review!

48391556_1839791506150500_8003351817255649280_nAs the end of the year approaches I thought that I would try to review some of the progress, if I can find any. Probably the biggest invisible improvements the world sees year to year are essential indicators of overall global public health, like rates of infant mortality, maternal mortality, childhood stunting, and teen pregnancy. These are important, because they represent access the average person alive has to health-care professionals, facilities, medicine, and more. All of these rates have been falling in the past few decades, in some cases dramatically, and every single one fell again in 2018.

The Health of the World In 2018, By The Numbers

Reporter Susan Brink noted that at year’s end, global health numbers offer reason for both hope and despair.

There is one strong positive note. An overriding public health finding is that people are living longer. “If that’s not a bottom line reason for optimism,” says Dr. Ashish Jha, director of the Harvard Global Health Institute and the T.H. Chan School of Public Health, “I don’t know what is.”

And then there are the million-plus cases of cholera in Yemen — deemed “a hideous milestone for the 21st century” by the International Committee of the Red Cross.

Note: Because of the way global numbers are gathered, it’s too soon to report on health statistics from the year now drawing to a close. There are only a few yet available for 2018 — polio cases, for example, and Ebola deaths in Democratic Republic of the Congo.

But there has been a constant stream of numbers released from the years just past. Unless otherwise noted, the numbers below represent the worldwide population.

7 Of Our Most Popular Global Health and Development Stories Of 2018

Life Expectancy

Worldwide life expectancy in 2016 was 72 years, up from 66.5 years in 2000.

The gain of 5.5 years in worldwide life expectancy between 2000 and 2016 was the fastest gain since the 1960s and reversed the declines of the 1990s caused by AIDS in Africa and the fall of the Soviet Union.

But life expectancy has been ticking down in the U.S. for three years: it was 78.9 in 2014; 78.8 in 2015; 78.7 in 2016; and 78.6 in 2017. An increase in deaths from opioids and from suicide is a possible reason for the trend.

Child mortality rates for children under five years of age have fallen from 216 deaths per 1,000 live births in 1950; to 93 deaths per 1,000 live births in 1990; to 40.5 deaths per 1,000 in 2016; and most recently to 39.1 deaths per 1,000 live births in 2017.

Health Care

3.6 million people died in 2016 because they had no access to health care.

5 million people, despite having access to health care, died in 2016 because the quality of care they received was poor.

In 2010, the year that the Affordable Care Act was signed into law, 49.9 million people in the United States, or 16.3 percent of the population under age 65, were without health insurance. In 2017, that number dropped to 28.9 million uninsured, or 10.7 percent of that segment of the population.

Yet also in 2017, the number of uninsured Americans increased by nearly half a million — the first increase since the Affordable Care Act was implemented.

HIV/AIDS

36.9 million people were living with HIV in 2017.

940,000 people died of AIDS-related illnesses in 2017.

35.4 million people have died from AIDS-related illnesses since the epidemic was identified in 1981.

Ebola

11,325 people died of Ebola in the epidemic of 2014-2016 in West Africa.

As of Dec. 23, there have been 347 confirmed deaths so far in the current Ebola outbreak in the Democratic Republic of Congo.

Air Quality

Pollution contributed to the deaths of some 9.9 million people in 2015 by causing diseases such cancer, heart disease and respiratory illnesses. That’s three times more deaths than the death toll from AIDS, tuberculosis and malaria combined.

Murder

Roughly 385,000 people were murdered around the world in 2017.

Hunger

Some 821 million people around the world did not get enough to eat in 2017. resulting in malnutrition, and about 151 million children under five experienced stunted growth due to malnutrition.

An estimated 1.9 billion adults were overweight or obese in 2016. 41 million children under five are overweight or obese.

Cholera

There were 1,207,596 suspected cases of cholera in Yemen between April 2017 and April 2018.

The total estimated number of cholera cases worldwide ranges from 1.4 million to 4 million.

Vaccinations

Global vaccination rates against childhood diseases in 2017: 85 percent. That number has stayed steady for several years.

In 2017, about 100,000 children in the U.S. under two, or 1.3 percent of children that age, had not been vaccinated against serious diseases like measles and whooping cough.

The percentage of unvaccinated U.S. children has quadrupled from 0.3 percent in 2001 — shortly after the circulation of erroneous and disproven reports that vaccines cause autism.

Polio

The number of cases of polio worldwide in 2018 as of Dec. 25 was 29, compared to 22 in 2017. There were an estimated 350,000 cases around the world in 1988.

A mysterious polio-like disease, called acute flaccid myelitis that can paralyze patients, mostly children, appeared in the U.S. in 2014 with 120 confirmed cases from August to December. There were 22 confirmed cases in 2015, 149 confirmed cases in 2016, 35 confirmed cases is 2017 and 182 cases as of Dec. 21, 2018.

Guinea Worm

In 1986, guinea worm disease, an incapacitating disease that creates painful lesions, affected some 3.5 million people in Africa and Asia. As of Oct. 1, 2018, there were 25 reported cases of guinea worm disease worldwide: 1 in Angola; 14 in Chad, and 10 in South Sudan. One obstacle to wiping it out entirely: The worm can circulate in dogs.

Mystery Disease

Number of cases of Disease X: Zero. But that doesn’t mean the World Health Organization isn’t worried about it. They use the term Disease X to refer to a pathogen “pathogen currently unknown to cause human disease” but that has the potential one day to trigger a deadly pandemic.

Healthcare in Congress for 2019: All Hat, No Cattle, Experts Say

News Editor, Joyce Frieden, in her end of the year report, noted that the work Congress does on healthcare next year — and even the year after — will be mostly for show without a lot of concrete results, experts said.

“Probably nothing is going to happen legislatively in the next 2 years around healthcare” in terms of legislation that is actually passed by both the House and Senate and signed by the president, said Chris Sloan, a director at Avalere, a healthcare consulting firm, in a phone interview. “I think the Democrats in the House are going to use this as an opportunity to showcase their policy priorities for 2020 — things like ‘Medicare for All’ or a Medicare buy-in, taking votes on those and nailing down some specifics.”

“You will also see Democrats in the House use their oversight power over [the Department of] Health and Human Services (HHS) — to hold hearings, and give pushback around things the administration is doing around the Affordable Care Act (ACA) like the expansion of association health plans and cuts in funding for marketing and outreach in the [health insurance] exchanges,” he said.

Sloan also expects a lot of activity to occur around drug pricing. “I’m not expecting a major piece of legislation around drug pricing coming out, but it’s a huge issue with a lot of traction on the right and the left… so I’d expect in the House and the Senate [to see] hearings on drug pricing,” he said. “There’s always a chance that the Democratic House and the Republican president will come together on some piece of drug pricing — like transparency reporting — but I think it’s unlikely. So the next 2 years won’t be stagnant for healthcare; there will be a lot of policy development but no major bills.”

Julius Hobson, Jr., JD, senior policy advisor at Polsinelli, a consulting firm here, was a little more optimistic — but only a little. “The first thing on my list is prescription drug pricing,” he said in a phone interview. “If there is an opportunity for Republicans and Democrats to work out something together — provided neither side tries to overreach — that will be the one thing that has the possibility of being enacted.” Possibilities for drug pricing legislation include bills supporting reimportation, pegging U.S. drug prices to those in Europe, or giving HHS the authority to negotiate drug prices under Medicare and Medicaid.

“After that, I can’t find a health issue at the moment that I think the two sides could work on,” Hobson said. “But I think we’ll see more hearings on the oversight of the ACA, especially in the House, as administration officials get dragged in to see what they’re doing.” A House floor vote on a ‘Medicare for All’ bill is also a possibility — although it won’t pass — along with more oversight on veterans’ healthcare, he added.

One area that gets little attention is healthcare costs at the Department of Defense, which is the fastest-growing portion of the budget, said Hobson. “Having been in wars for 17 years, our healthcare costs are going through the roof.” Both President George W. Bush and President Obama pushed for having military members pay more of their costs under the Tricare health insurance program for military families, “but Congress refused to do that.”

Instead of action in Congress, most of the activity on the healthcare front will probably be within the Trump administration, he continued. “There will be more attempts to get things done — things [the administration] can do that Congress is unable to do.” Expect more efforts to come from the Office of Regulatory Reform at the Centers for Medicare & Medicaid Services, “which is consistent with an executive order from last year to come up with lists of regulations they could do away with to make the system less burdensome,” Hobson predicted.

Rodney Whitlock, vice president for health policy at ML Strategies, a consulting firm here, said in a phone interview that he expected some effort to pass a bill related to Texas vs. the United States of America — the court case questioning the constitutionality of the ACA — “and I think there’s something that looks a little more like ACA stabilization in the works… [The question is] what is the difference between the things where they’re trying to make a point versus what might be actually statutorily possible.”

Bob Laszewski, president of Health Policy and Strategy Associates, a consulting firm in Alexandria, Va., agreed with the idea that both parties will be focused on the drug pricing issue. “This seems to be about the only bipartisan interest and it will be interesting to see if there is any real agreement between them,” he said in an email. “Trump’s reference pricing proposal could be an interesting spot — will he find more Democratic allies than Republicans?”

Healthcare-related taxes imposed by the ACA but not yet implemented — including taxes on “Cadillac” health insurance plans and medical devices — are another possible area of cooperation, he said. “These have only been postponed and will have to be dealt with. There does seem to be broad agreement they should not be restarted.” And the pharmaceutical industry will be pushing back against a proposal to have it pay a larger share of drug costs in the Medicare Part D “donut hole,” he added.

Finally, “Democrats will have as their top priority rubbing salt into the Republican wounds on pre-existing conditions and the recent Texas court case,” Laszewski said. “I don’t see any opportunity for bipartisan fixes. With the Supreme Court more than a year away in terms of any final decision, this will be a very dark cloud in 2019.”

Bookended by Obamacare, 2018 was the year of policy change

As Susannah Luthi points out in 2018 tith Congress’ attempt to repeal the Affordable Care Act dead by the end of 2017, any relief the law’s supporters felt were likely short-lived, as 2018 was the year the Trump administration began significantly remolding a law it fundamentally opposes.

Led by HHS Secretary Alex Azar, who took the reins of the $1.2 trillion department last January, the administration charted an overarching strategy to lower drug prices and reduce spending on hospital care. Moreover, by the end of 2018, the entire Affordable Care Act was back in legal peril when a federal judge in Texas struck it down and blocked immediate appeal.

Here’s a look at the major healthcare political issues of 2018, a year when the public political drama slowed down, but activity aiming to overhaul the ACA sped up.

Drug prices

During Azar’s confirmation hearing last January, he faced skeptical Senate Democrats who argued his tenure as a top executive with pharmaceutical giant Eli Lilly & Co. could blunt the Trump administration’s promised plan to lower drug prices.

The skepticism didn’t abate when White House in May unveiled its blueprint. But as the policy bones gained muscle, Azar’s ideas have won over some doubters and drawn manufacturer ire.

“The biggest news item of the year is that the drug blueprint wasn’t hot air and that they’re really trying to do big things,” said Michael Adelberg, a healthcare consultant with the law firm Faegre Baker Daniels. “Like many others, I assumed it was mostly PR, but I think the administration deserves credit for taking this seriously.”

Among the most controversial policies: a mandatory international pricing index model for Part B physician-administered drugs to align prices with those in other countries.

Critics on the left who want Medicare to negotiate directly said the policy falls short. Investment analysts hope the proposal is a tactic to bring manufacturers to the negotiating table.

Critics on the right say it’s price-fixing.

“Proposing to effectively accept the pricing decisions of other countries, while having the chutzpah to brand the policy ‘market-based’ is beyond disappointing,” said Benedic Ippolito of the American Enterprise Institute.

Last month the administration also proposed a significant change to Medicare Part D that sparked outcry: room for price negotiation for drugs in protected classes, where Medicare costs are exceptionally high. Patient groups are fighting back over concerns about access, but the administration says Part D has substantial patient protections in place, and the chronically ill will always be able to get critical medications.

Site-neutral payments

HHS has also took action on site-neutral payments for Medicare, and despite pending litigation, analysts believe the political winds on the issue may have changed.

Last month the administration finalized a rule that will slash payments for office visits at hospital outpatient clinics to match the rate for independent physicians’ offices. In response, two powerful industry groups sued.

But nonpartisan experts have wanted to see this policy move—not only to address rising Medicare expenses but also consolidation and the rising costs that stem from that trend. “In an era of growing consolidation of providers and increasing physician employment by hospitals, site-neutral payments are critical on all dimensions,” said Paul Ginsberg, director of the USC-Brookings Schaeffer Initiative for Health Policy at the Brookings Institution.

Hospitals will keep fighting hard against them, Ginsberg added. But from his vantage point, analysts’ views on the issue have expanded to what’s at stake for the entire healthcare system in terms of this policy, and they are increasingly bipartisan.

“I’ve had the sense that (the administration) has long seen the issue of healthcare competition as something they can work with Democrats on,” he added. “And I think Democrats are much more comfortable using competition than they have been historically. So that’s a political dimension that makes it more promising that this policy could be sustained.”

340B program

The administration also trimmed reimbursement in the 340B drug discount program, which avoided congressional reforms despite Senate hearings and introduction of several House bills.

Hospitals had a key win late this year when HHS jumped ahead of its stated deadline and said it will start capping the prices manufacturers can charge providers for drugs. Regulation over ceiling prices for 340B has been delayed for years and early this fall hospitals sued over the latest postponement.

But litigation over the sweeping cuts to Part B drug reimbursements for 340B hospitals is still pending, and the administration has expanded those cuts to hospital systems’ off-campus facilities.

Affordable Care Act

A proposal to stabilize the individual market with a federal funding boost fell apart early in the year as a band of Republican-led states sued to overturn the law following the effective elimination of the individual mandate penalty for 2019.

Still, Obamacare may survive this attack. Sabrina Corlette, from Georgetown University’s Center on Health Insurance Reforms, said that in 2018 the law proved the doubters wrong. “It revealed remarkable resilience in the face of some pretty dramatic attempts to roll back or undo the law,” she said.

The individual market remains in a holding pattern. Shortly before open enrollment started this year, CMS Administrator Seema Verma touted the fact that premiums dropped for the first time since the law was implemented.

Premiums for benchmark silver plans on the federal individual market exchanges will drop in 2019, marking the first decrease since the Affordable Care Act was implemented, CMS Administrator Seema Verma announced on Thursday.

Verma attributed the 1.5% overall drop to looser regulations, the Trump administration’s market stabilization rule and the seven 1332 State Innovation Waiver approvals that launched reinsurance programs.

Tennessee will see the sharpest premium decline, as average monthly premiums for silver plans fell more than 26%, from more than $600 last year to $449. North Dakota had the greatest increase, with average premiums rising more than 20% from $312 per month to $375. Sixteen of the 39 states using the federal exchange will see declines, two states will have no change and the majority of the remaining states will face marginal, single-digit increases.

Verma dismissed the idea that President Donald Trump’s cut-off last year of the cost-sharing reduction payments hurt the market, although the action was followed by a nearly 40% jump in average premiums as insurers added the cost to benchmark silver plans in a move known as “silver loading.”

Analysts have credited the slim premium increases insurers have announced so far this year as a correction to excessive 2018 rate hikes.

But Verma defended the expansion of short-term, limited duration plans as an affordable option for people who can’t afford Obamacare plans. Potentially, they could appeal to the 20 million Americans who don’t have coverage, she added.

“The prediction was that the offering of short-term plans would have negative impact on the market and increase premiums, but we’re not seeing the impact on the market,” Verma said.

The administrator also announced the administration will be writing new guidance for 1332 waivers to allow states to broaden exchange plan design “to create more affordable options,” but said the new reinsurance programs are a key part of the overall drop in premiums.

Federal exchange states that launch reinsurance programs in 2019 will see decreases in premiums as expected, but prices will not fall to pre-2018 levels. Wisconsin, which had its 1332 waiver approved earlier this year, will see a drop in averages from $464 in 2018 to $440 for 2019. In 2017, average silver plan premiums in the state were just over $300. Maine’s average premiums will decline from $482 in 2018 to $446 in 2019, still more than $100 per month higher than the $316 in 2017.

New Jersey will see the sharpest decrease with its reinsurance waiver. In 2017, average silver premiums were $286 per month, rising to $339 per month this year. With reinsurance, they will settle in at $286 per month in 2019.

Last year, Alaska — which has the highest insurance premiums in the country — saw a drastic decline after implementation of its waiver. Average monthly premiums fell from $759 in 2017 to $595 in 2018. Next year they will drop again to $576.

The CMS hasn’t made enrollment projections for 2019 based on these new numbers, but Verma added that more people may opt for the federal exchanges “when we’re not seeing double-digit rate increases.”

Verma said the administration still wants changes to Obamacare’s exchange rules.

“For millions of people, the law needs to change,” she told reporters. ” While some have publicly been accusing us of sabotage, we have been doing everything we can to mitigate problems of Obamacare.”

The high cost of stabilization continues to trouble many. “ACA markets have stabilized at an unsatisfactory point,” said Douglas Holtz-Eakin, a conservative economist and former director of the Congressional Budget Office.

He said the deep cuts to marketing and other changes “all do matter at the margins” and that the slower enrollments noted this year have borne this out. “You have to decide what the administration’s objective is politically,” he added. “They don’t want to expand enrollment: they want it stabilizing,” but it’s coming at a high cost.

Adelberg said while plans aren’t “hemorrhaging money and going out of business” as they were in the early years, the exchange market still very much depends on subsidies and looks more like a tier of Medicaid.

“The exchange market is starting to look like Medicaid expansion-expansion,” he said.

The CMS has tweaked guidance for Section 1332 state innovation waivers, sparking criticism that the administration opened the door to trimming protections.

Potential actions from the administration take on extra weigh in light of the late-breaking court decision over Obamacare.

But even strong critics of the law doubt the administration would use the murky legal situation to cross statutory lines with waiver approvals in the meantime.

“No one wants to do anything in the interim, and both sides are waiting for the final, final decision,” said conservative policy analyst Chris Jacobs.

Medicaid public option

States this year started a serious push for their own form of the public option through Medicaid and some in Washington have started paying attention.

Minnesota, Nevada and New Mexico are some of the states that have forged ahead with studies on this policy. And with congressional activity on healthcare likely on hold until after the 2020 presidential election, advocates see this year’s progress on the state level with this policy as significant—even if the industry is on the alert about potential revenue hits.
Adelberg said he is tracking the discussion closely and is particularly interested in the option if it’s offered outside the Obamacare exchanges

I have previously stated and I will restate my opinion, that unless civility, maturity, and a dedication to do what is best for the voters, nothing will get done in healthcare in the next 2 years with the Democrats using the failure as one of many talking points to get elected. These will be depressing 2 or more years of frustration. But I will continue my discussion regarding the options for our healthcare system and hopefully offer what I believe is the best form of healthcare delivery for all in our wonderful country.

Happy New Year to All!!

 

 

Suicide Rate Up 33% in Less than 20 years, Yet Funding Lags Behind Other Top Killers!

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First let us all take a minute to remember Past President 41, George H.W. Bush, probably one of the most respected past presidents. is experience, knowledge, and experience was amazing and so welcomed and useful to run a country. This former president has inspired us all with his toughness mixed with judiciousness and kindness. We could all learn much from 41! Now a moment of silence…………………..

Suicide rates are up 33% in the U.S., yet funding lags behind that of all other top causes of death — leaving suicide research in its “infancy.”

More than 47,000 Americans killed themselves in 2017, the Centers for Disease Control and Prevention reported Thursday, contributing to an overall decline in U.S. life expectancy. Since 1999, the suicide rate has climbed 33 percent.

Americans are more than twice as likely to die by their own hands, of their own will, than by someone else’s. But while homicides spark vigils and protests, entering into headlines, presidential speeches, and police budgets, suicides don’t. Still shrouded in stigma, many suicides go unacknowledged save for the celebrities – Robin Williams, Kate Spade, Anthony Bourdain – punctuating the unrelenting rise in suicide deaths with a brief public outcry.

And research suggests our ways of living may be partly to blame, in ways that don’t bode well for the future.

Alcohol and substance abuse are risk factors, and both are increasing. Isolationraises the risk, and nearly half of Americans say they sometimes or always feel alone. Increasing smartphone use has been linked to suicidal thoughts in teens. Even climate change has been found to have roughly the same effect on increasing suicides as an economic recession.

The leading causes of death have declined since 1999

The Suicide rate has increased more the 33%

Screen Shot 2018-12-01 at 10.16.49 PM“We’re trying to reduce suicide death rates in the face of a culture that’s ever more fascinated with violence, that has a bunch of opiates around left and right, where family structure isn’t getting more cohesive and neither is community structure,” said Thomas Joiner, a leading suicide researcher. “That’s a lot to fight against.”

Suicide is the 10th leading cause of death in the U.S. and is often called a public health emergency.

But money to research and combat suicide continues to lag behind other leading killers and even non-fatal conditions. The National Institutes of Health, the largest public funder of biomedical research in the world, spent $68 million on suicide last year. It spent nearly five times that studying sleep and 10 times more on breast cancer, which killed fewer people in 2016.

“What I’m just painfully aware of is that all of the areas where the top 10 causes of death in the United States have gone down have received significantly more attention,” said John Draper, director of the National Suicide Prevention Lifeline. “There’s been so much more put into every one of those causes of death than suicide. … If you didn’t do anything for heart disease and you didn’t do anything for cancer, then you’d see those rates rise, too.”

NIH officials say they do not expressly budget by disease, and research funding in other categories could affect suicide without being suicide-specific. The NIH spent $2.7 billion on mental health, for example.

“A large portion of the research is not disease-oriented but based on human biology. For instance, if we’re studying brain function, it might be pertinent to suicide, but we might not necessarily categorize it as suicide,” said Michael Lauer, NIH deputy director for extramural research. “Same with depression, which obviously is linked to suicide.”

Still, many in the field wish for dedicated spending. Jill Harkavy-Friedman, vice president of research for the American Foundation for Suicide Prevention, advocates for $150 million a year for suicide research, still far less than the $592 million the NIH allocated to fight kidney disease, the nation’s No. 9 killer.

“We are happy that other health conditions are getting the money. … It’s not an either/or,” Harkavy-Friedman said. But “the cost of suicide is enormous, and people don’t realize it.”

The cost — in dollars, in suffering, in science

Suicides and suicide attempts cost $93.5 billion a year, most of it in lost productivity, a 2016 study estimated. And that’s nothing compared with the cost in human lives and suffering.

Joiner recognized the human toll 30 years ago – even before his own father died by suicide.

As a graduate student in psychology in 1990, Joiner had begun focusing on depression. That summer, his father, a former Marine sergeant turned software pioneer, took his own life.

“He was a successful, visionary, ambitious, intelligent man,” Joiner said. “And he had an illness that ended up being fatal. That’s how I see him.”

Joiner, now a psychology professor and clinician at Florida State University, said his father’s death helped persuade him to make studying suicide his life’s work.

“I’d already inclined toward that decision, and this only made it starker. I already knew this was a problem,” he said. “It was a misery for the bereaved, and that’s not to mention the even more acute suffering suicidal people go through in the hours, days, months before their death – just a lot of suffering all around. And it wasn’t being studied then.”

It’s studied now, but given the size of the problem, we still know surprisingly little about it.

“I think that we’ve told the public that we know more about suicide than we know,” said April Foreman, a clinician on the American Association of Suicidology board of directors.

When someone dies by suicide, people and the media trot out a series of “maybes,” she said: Maybe it was mental illness. Maybe it was losing a job or getting divorced.

“Maybe it was not getting a phone call at just the right moment. Maybe. But maybe something was happening in their brains that in 20 years we’ll understand,” she said. “We tell stories about bullying or sadness like it’s a fairy tale. There’s probably real science there, and we just haven’t decided to treat it like that. … We’re telling stories about why people kill themselves that isn’t scientifically based, that are very inaccurate, and are just the easier stories to tell because it’s much harder to say we don’t know.”

Joiner compares suicide research today to “cancer research about 100 years ago.”

“People were so scared of the topic they wouldn’t even say the word,” but cancer research has since made great strides, he said. “I think the same thing will happen with suicide research, but that’s decades in the future. Right now we’re in our infancy.”

Suicide studies reflect the broad sweep of the current science. Some focus on genetic factors involved in maintaining brain circuits and neurotransmitters, biomarkers of at-risk populations, brain PET imaging and medications; others focus on psychotherapies, preventing substance abuse and school nurse interventions.

The effectiveness of prevention efforts has been difficult to determine as suicide rates increase, said Andrew Sperling, director of legislative affairs for the National Alliance on Mental Illness.

“The challenge is there are various suicide prevention programs, and we’re still learning a lot about what works and doesn’t work,” Sperling said. “There’s not a lot of evidence we’ve been very effective at it.”

Scientific knowledge is limited. Public knowledge is wrong.

Even key discoveries that enjoy broad support among researchers have yet to percolate into the public consciousness. 

Public health experts say: Suicide is preventable.

People think: Suicide is inevitable.

Consciously or unconsciously, many Americans write off those who seriously consider killing themselves as hopeless causes, unreachable. A study in 2017 showed that people are skeptical of a suicidal person’s ability to recover – the idea that even if we stop the person today, we won’t tomorrow.

“If you think once someone’s suicidal that they’re just going to die, then it doesn’t make sense to invest money in that,” Joiner said of a common point of “ignorance.”

Science tells us that isn’t true. So does common sense. Survivors of suicide attempts themselves are walking proof.

In 2016, nearly 45,000 died by suicide, but the number who attempted is almost 29 times that — meaning more than one and a quarter-million survived. Though a previous suicide attempt makes the risk of dying by suicide higher, it is just one of many risk factors. Nine out of 10 people who survive a suicide attempt will not go on to die by suicide later, according to studies that have tracked survivors over decades.

Cliff Bauman, a National Guardsman who struggles with post-traumatic stress disorder, attempted suicide once, but when he faced a crisis again he was able to get through it by using learned coping skills, including being aware of his triggers and having people he can trust.

“I made the conscious decision (after my attempt) to go back into counseling,” he said. “(I) was opening up about why I did what I did and how it got to that point, and I felt suddenly … the darkness doesn’t seem so dark.”

Another misconception is that suicidal ideation is rare. But one in 33 American adults seriously thought about suicide in 2016, the commonness of the thoughts belied by how rarely they’re discussed.

“Suicide is reflective of other issues that we don’t want to talk about,” said Adam Swanson, a senior prevention specialist at the Suicide Prevention Resource Center. “We don’t want to talk about the fact that people can’t afford to pay electric bills. … We don’t want to talk about the … pain people carry.”

Survivors are often the first to distinguish that it’s not a desire to die that drove their attempt but a desire to escape the pain. It’s something Shelby Rowe, a PTSD and suicide attempt survivor who works in suicide prevention knows firsthand.

“If I could go back to talk to myself that night when all I could hear in my head was ‘You can’t live like this anymore, you can’t live like this anymore’ … I would have said: ‘It’s OK, you’re right. It is really awful right now, and you can’t live like this anymore, but please live, because there is another way. There is another beautiful life waiting for you.'”

Mental and emotional pain is less acknowledged – both by doctors and the public – than physical pain, Foreman noted.

“It is OK for someone to suffer from wanting to kill themselves and to suffer from trying to kill themselves or even die that way, but it’s not OK to feel sick with the flu for a few days,” she said.

Stymied by stigma

The lack of compassion people feel for those who die by suicide is reflected in the lack of funding. Stigma goes beyond misconceptions.

“Stigma is about fear, and suicide is associated with our most primal fears – fear of death … fears of traumatic loss and our fears of mental illness,” Draper said.

Fear and discomfort also can be expressed as anger.

Retired California Highway Patrol officer Kevin Briggs said he has heard drivers shout “Go ahead and jump!” to people contemplating suicide on the Golden Gate Bridge.

The taunts reflect a disdain some people feel toward those who attempt suicide, whom they see as “weak” or “crazy,” a 2017 study found. Though mental illness is a risk factor for suicide, not everyone who is mentally ill has suicidal thoughts, and not everyone who attempts suicide is mentally ill.

But even statistics on the relationship between mental illness and suicide are incomplete “because we’re not funding it,” Harkavy-Friedman said.

“Every year we go to (Capitol) Hill and we advocate at the state level for fully funding the National Violent Death Reporting System,” she said.

The tracking system, now in place in just 40 states, helps health experts and law enforcement officials identify common circumstances associated with specific types of death, including suicide. Suicide can be especially hard to track without a strong system in place because family members may try to cover it up or pressure officials not to enter “suicide” into records.

In the past, even in clear cases of suicide, families were “not telling anybody for years because they thought they would be blamed or stigmatized,” Harkavy-Friedman said.

Stigma is not only an obstacle to accurate reporting, but it also has made politicians shy away. It’s part of why suicide wasn’t seriously studied or even discussed until the past few decades.

“Twenty years ago when I worked on (Capitol) Hill, you wouldn’t find suicide prevention on federal documents. It wasn’t talked about in the Department of Defense or in the general public. There were no researchers. There was no national strategy for suicide prevention,” said Jerry Reed, a doctor on the executive committee for the National Action Alliance for Suicide Prevention.

That changed in 1998 when Congress declared suicide a national problem, Reed said.

“Since then, the country has caught up to the significance of this issue, but it still has a long way to go.”

Congressional support is key because it affects the overall NIH budget. Congress also can pass special provisions regarding certain issues, as it has for Alzheimer’s and opioid abuse.

“Congress has made that a clear priority,” Lauer said.

Where’s the hope? A little bit in a lot of places

Despite challenges, experts agree our understanding of suicide is light-years ahead of where it was just a generation ago. And suicide prevention is at “unprecedented” levels, the Substance Abuse and Mental Health Services Administration reports.

Therapy

Through interventions, including medication and therapy, Joiner says he sees suicidal patients at his clinic go from “pretty desperate, pretty intent to die” to “turn(ing) a corner – and usually it’s shockingly quick.”

Joiner theorizes that suicide results from a combination of factors: feeling like a burden, isolation, and having lethal means and a lack of normal fear of death.

Short-circuit one of that – isolation, for instance – and you might stop someone from hurting himself.

“It stands to reason if you reconnect a little bit then risk should abate, so we just arrange within the context of people’s day-to-day lives small increased doses of social connection,” Joiner said. “It’s a very simple behavioral idea, but it seems to work if people do it.”

Asking a friend to lunch would be a great example, Joiner said, but some patients don’t have a friend. They might start simply with “show up to this community event and stay for 10 minutes.”

Of course, some people are chronically suicidal, but Joiner and others note that they can also feel relief through targeted therapy.

Shear Avory, a transgender person who sees a therapist (not associated with Joiner), has lived with daily suicidal ideation and continues to hold on to hope.

“For so long I’ve been stuck in just wanting everything to disappear, from wanting the trauma to go away,” said Avory, whose traumatic childhood included foster homes and conversion therapy. “I’m still alive. I’m still here. That feels like an accomplishment. … Healing is not a linear experience.”

Low-cost changes to health care

With unlimited funding, Joiner said he’d put resources toward practical things proven to work, such as “means safety” – which can include everything from putting pedestrian barriers on bridges to locking up guns and medicine cabinets – and training doctors to identify at-risk patients.

Training primary care doctors and other medical staff is the foundation of the Zero Suicide program.

Zero Suicide founder Mike Hogan said that though suicide is incredibly complex, determining who is at risk can actually be very simple: Once patients are in a health care setting, ask them. Studies have shown that asking people if they’re thinking about suicide does not plant the idea in their heads.

“If people are asked, they often really want to get it off their chest, and they want some help, and it opens the door to help,” Hogan said. “A little bit does a lot: asking, safety planning, reducing lethal means and reaching out … turns out to be quite powerful.”

A 2014 study found that 83% of those who die by suicide saw a health care provider in the year before their death. That’s particularly true for older white men, who account for most suicides.

“We can’t predict when they’ll die, just like we can’t predict when someone might die of a heart attack,” Hogan said. “But we can predict who needs a little help just like someone might need help because their lipid levels are high.”

Hogan said two nonprofit organizations that offer mental health treatments – Centerstone, which spans multiple states, and the Institute for Family Health in upstate New York – saw roughly 60 percent reductions in suicides after adopting Zero Suicide.

Becky Stoll, vice president for crisis and disaster management at Centerstone, said one of the biggest improvements has been the methodical approach to plugging holes in care. For instance, coordination between the suicide prevention committee and their IT department resulted in a program that changed the font color of high-risk patients if they missed appointments, which would then alert them to start calling the patient. If the patient didn’t answer, they’d start calling their friends and family. It was a simple change and it saved lives. In one case, a man’s wife called him after she had received calls from Centerstone. He had been standing on a bridge at the time.

“I’ve been in the field since the late ’80s, and I’ve not seen the enthusiasm the results that we’re seeing now,” Stoll said. “We don’t win every time, but we win a lot. When we know better, we have to do better. And embedding these frameworks into systems of care … it really does seem like we can have an impact. It seems like that’s catching wildfire across the U.S. … (We need to) make people feel they have lives worth living.”

Colorado has embraced Zero Suicide as one tool in its fight. But advocates are more closely watching the newly formed Colorado-National Collaborative, a partnership aimed at reducing suicides thereby 20percent by 2024.

Through a combination of funding from state and federal sources and the American Foundation for Suicide Prevention, Colorado’s Office of Suicide Prevention went from an annual budget of $536,000 about 18 months ago to $2.6 million as of Sept. 30. If the partnership between scientists and public health professionals proves effective in the state with the eighth-worst suicide rate in the country, it could be adopted nationwide.

Removing the means

Colorado and other states also have joined the Gun Shop Project, in which gun store owners and firing range instructors distribute suicide prevention materials as part of an effort to reach people who might be looking for a tool to commit suicide.

Guns were used in 23,000 of the 45,000 suicide deaths in 2016.

These interventions focus on the “means,” or how suicides are completed.

“We may not understand suicidality very well … (but) we know people don’t die of feeling suicidal – they die from a gunshot wound, they die from a medication overdose. Just like you don’t die by (a driver) having poor depth perception, you die from them striking the car and your head hitting the windshield,” Foreman said.

‘On the cusp’?

Many in the suicide research and prevention field describe it as being on a precipice – the science is not where it needs to be, but it shows promise; the funding is not where it needs to be, but it has increased. On the other side, they hope, are the results: a nation in which fewer lives are lost to suicide or tormented by suicidal thoughts.

“With suicide, I hope that we’re on a cusp of a movement,” Foreman said. “Where the people who have survived suicide attempts, the people who live with chronic suicidality, the families, the loved ones, the people who are left, that they get up and say: This suffering is the same as someone who has died by HIV … or cancer. It deserves the same quality science.”

Suicide, at a 50-year peak, pushes down US life expectancy

Mike Stobbe wrote that Suicides and drug overdoses pushed up U.S. deaths last year, and drove a continuing decline in how long Americans are expected to live.

Overall, there were more than 2.8 million U.S. deaths in 2017, or nearly 70,000 more than the previous year, the Centers for Disease Control and Prevention said Thursday. It was the most deaths in a single year since the government began counting more than a century ago.

The increase partly reflects the nation’s growing and aging population. But it’s deaths in younger age groups—particularly middle-aged people—that have had the largest impact on calculations of life expectancy, experts said.

“These sobering statistics are a wake-up call that we are losing too many Americans, too early and too often, to conditions that are preventable,” Dr. Robert Redfield, the CDC’s director, said in a statement.

The suicide death rate last year was the highest it’s been in at least 50 years, according to U.S. government records. There were more than 47,000 suicides, up from a little under 45,000 the year before.

A GENERAL DECLINE

For decades, U.S. life expectancy was on the upswing, rising a few months nearly every year. Now it’s trending the other way: It fell in 2015, stayed level in 2016, and declined again last year, the CDC said.

The nation is in the longest period of a generally declining life expectancy since the late 1910s, when World War I and the worst flu pandemic in modern history combined to kill nearly 1 million Americans. Life expectancy in 1918 was 39.

Aside from that, “we’ve never really seen anything like this,” said Robert Anderson, who oversees CDC death statistics.

In the nation’s 10 leading causes of death, only the cancer death rate fell in 2017. Meanwhile, there were increases in seven others—suicide, stroke, diabetes, Alzheimer’s, flu/pneumonia, chronic lower respiratory diseases, and unintentional injuries.

An underlying factor is that the death rate for heart disease—the nation’s No. 1 killer—has stopped falling. In years past, declines in heart disease deaths were enough to offset increases in some other kinds of death, but no longer, Anderson said.

(The CDC’s numbers do sometimes change. This week, CDC officials said they had revised their life expectancy estimate for 2016 after some additional data came in.)

WHAT’S DRIVING IT?

CDC officials did not speculate about what’s behind declining life expectancy, but Dr. William Dietz, a disease prevention expert at George Washington University, sees a sense of hopelessness.

Financial struggles, a widening income gap, and divisive politics are all casting a pall over many Americans, he suggested. “I really do believe that people are increasingly hopeless and that that leads to drug use, it leads potentially to suicide,” he said.

VoteCast, a wide-ranging survey of the electorate conducted by The Associated Press, found voters expressing pessimistic views about the future: About half of voters nationwide said they expect life in America for the next generation to be worse than it is today. Nearly a quarter said life would be better and about as many said it would be the same. VoteCast surveyed more than 115,000 voters nationwide as Americans cast ballots in this year’s midterm elections.

Drug overdose deaths also continued to climb, surpassing 70,000 last year, in the midst of the deadliest drug overdose epidemic in U.S. history. The death rate rose 10 percent from the previous year, smaller than the 21 percent jump seen between 2016 and 2017.

That’s not quite cause for celebration, said Dr. John Rowe, a professor of health policy and aging at Columbia University.

“Maybe it’s starting to slow down, but it hasn’t turned around yet,” Rowe said. “I think it will take several years.”

Accidental drug overdoses account for more than a third of the unintentional injury deaths, and intentional drug overdoses account for about a tenth of the suicides, said Dr. Holly Hedegaard, a CDC injury researcher.

OTHER FINDINGS

The CDC figures are based mainly on a review of 2017 death certificates. The life expectancy figure is based on current death trends and other factors.

The agency also said:

—A baby born last year in the U.S. is expected to live about 78 years and 7 months, on average. An American born in 2015 or 2016 was expected to live about a month longer, and one born in 2014 about two months longer than that.

—The suicide rate was 14 deaths per 100,000 people. That’s the highest since at least 1975.

—Montana had the highest suicide rate, and New York the lowest. Suicide rates were nearly twice as high in rural counties than in urban ones.

—The percentage of suicides due to drug overdose has been inching downward.

—Deaths from flu and pneumonia rose by about 6 percent. The 2017-2018 flu season was one of the worst in more than a decade, and some of the deaths from early in that season appeared in the new death dates.

—West Virginia was once again the state with the highest rate of drug overdose deaths. The CDC did not release state rates for suicides.

—Death rates for heroin, methadone, and prescription opioid painkillers were flat. But deaths from the powerful painkiller fentanyl and its close opioid cousins continued to soar in 2017.

—Gun deaths rose for the third year in a row, to nearly 40,000. That’s about 1,000 more than in 2016. They had been hovering around 33,500 deaths until a few years ago.

Like in other years, most gun deaths were suicides. Earlier CDC reports have noted increasing rates of suicide by gun. In 2017, it about 60 percent of them were by gun.

More next week as I discuss the discussion that we need to have and those who are left behind and suffer the most.

Suicide Lifeline: If you or someone you know may be struggling with suicidal thoughts, you can call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255) any time of day or night or chat online.

 

 

 

California Fire: What is the Impact on Health in the Long Run and the Relationship to Climate Change? Also, Consider What Happens When We are Outspoken on Gun Violence.

 

39500554_1676963889099930_3922787849857925120_nThis next interesting report struck a nerve when my daughter in northern California called me because she was having difficulty finishing her daily 7 miles run without getting short of breath. The administrators at her graduate school were advising students to exercise at the inside facilities.

“There is simply no president for this”Salynn Boyles at the International ACAAI Annual Scientific Meeting wrote that the short- and long-term health impact of environmental events, such as the Camp Fire in California, on large populations are not well understood, according to experts at the American College of Allergy, Asthma, and Immunology (ACAAI) annual scientific meeting.

The Camp Fire, which was still burning across more than 200 miles of Northern California on Sunday, ranked among one of the worst natural disasters in the U.S. this century, with the death toll continuing the climb and close to 1,300 people still counted among the missing.

After burning for more than a week, the fire elevated air pollution levels in San Francisco and the surrounding areas to the point where the region reportedly has the poorest air quality on the planet.

Most outdoor events in San Francisco (about 180 miles from the fire zone) on Saturday were canceled or postponed, including the game between football rivals Stanford University and the University of California Berkeley. San Francisco officials also took the city’s iconic open-air cable cars out of commission due to the poor air quality.

David Peden, MD, of the University of North Carolina Gillings School of Global Public Health in Chapel Hill, spoke about the Camp Fire at an ACAAI session on the impact of the environment on allergic disease.

“At these levels, any outdoor activity is dangerous for people with chronic diseases like COPD [chronic obstructive pulmonary disease] or heart disease,” Peden said. “Everyone understands the allergy risk and the risk for other airway diseases. But there is a clear signal of inflammation in cardiac disease and breathing pollution triggers inflammation.”

Peden, who studies the role of air pollution in the airway and cardiovascular disease, noted that while California has seen wildfires of increasing frequency and intensity, other regions of the country are also increasingly vulnerable as drought conditions intensify. These areas include eastern Montana, western portions of the Dakotas, and large parts of the Mexican border.

Peden, along with ACAAI attendee Katherine Gundling, MD, of the University of California San Francisco, told MedPage Today that current air quality in San Francisco — reported to be in the very unhealthy PM2.5 range of 201-300 on Saturday — compared unfavorably to some of the most polluted areas of China and India, which have average air quality PM2.5 in the range of 100-150.

Peden stated that during the 2013 California Rim Fire, daily air pollution exposure levels among people in urban areas affected by the fire were up to 35 times greater than the 24-hour PM2.5 standard (35μg/m3) considered safe by the Environmental Protection Agency (EPA).

Gundling agreed that it will take time to understand the short- and long-term health impact of events like the Camp Fire.

“There is simply no precedent for this,” she told MedPage Today. “We are used to wildfires, but not fires that kill large numbers of people who have no chance of escape. That is the new and horrible reality we are living.”

She added that the increasing frequency and intensity of the California fires should serve as a wake-up call for the country.

“These fires are different,” she said. “It’s not just that there are more of them and that they are more severe. It’s a number of factors. It’s climate change. It’s forest management. All of this has to be addressed.”

Forecasts were for air quality to remain in the unhealthy 100-200 range through Tuesday in San Francisco, the East Bay, and other parts of the Bay area. Rain bringing wind is expected in the area on Tuesday.

Public health officials advised residents to stay indoors whenever possible and wear N95 masks when outdoors. Some city governments and independent organizations are distributing face masks.

Now consider a research study, which looked at air pollution and intellectual disabilities in children.

Climate Change Is Already Hurting U.S. Communities, Federal Report Says

Rebecca Hersher discussed on All Things Considered that climate change is already causing more frequent and severe weather across the U.S., and the country is poised to suffer massive damage to infrastructure, ecosystems, health and the economy if global warming is allowed to continue, according to the most comprehensive federal climate report to date.

The fourth National Climate Assessment is the culmination of years of research and analysis by hundreds of top climate scientists in the country. The massive report details the many ways in which global climate change is already affecting American communities, from hurricanes to wildfires to floods to drought.

“Climate change is already affecting every part of the United States, almost every sector of the United States, be it agriculture or forestry or energy, tourism,” says George Mason University professor Andrew Light, who is one of the report’s editors. “It’s going to hurt cities, it’s going to hurt people in the countryside, and, as the world continues to warm, things are going to get worse.”

President Trump, numerous Cabinet members and some members of Congress have questioned whether humans cause climate change or whether it is happening at all.

“I don’t think there’s a hoax. I do think there’s probably a difference. But I don’t know that it’s man-made,” the president said on CBS’ 60 Minutes in October.

In an August interview about deadly wildfires in California, Interior Secretary Ryan Zinke told television station KCRA Sacramento: “This has nothing to do with climate change. This has to do with active forest management.”

The new report, mandated by Congress and published by the U.S. Global Change Research Program, is the latest and most detailed confirmation that humans are driving climate change and that Americans are already adapting to and suffering from its effects. Climate change is “an immediate threat, not a far-off possibility,” it says.

For example, large wildfires are getting more frequent because of climate change. The report notes that the area burned in wildfires nationwide each year has increased over the past 20 years, and “although projections vary by state and or region, on average, the annual area burned by lightning-ignited wildfire is expected to increase by at least 30 percent by 2060.”

Millions Of Acres Burned By Wildfires In The U.S. From 1985 To 2017

Screen Shot 2018-11-25 at 11.36.57 PMAlthough California and other Western states have made headlines for deadly fires, the report says the southeastern U.S. is also projected to suffer more wildfires.

Many regions are also experiencing more extreme rain — and ensuing floods — including the Midwest, Northeast, Southeast and Southern Great Plains, which includes Texas and Oklahoma. The most extreme example is Hurricane Harvey, which dumped 60 inches of rain on parts of southeast Texas in 2017 and flooded an enormous region from Houston up to the Louisiana border.

And the authors make clear that more extreme rainfall and flooding is widespread, going beyond major hurricanes. In the Midwest, runoff from heavy rains has depleted some cropland of nutrients. In the Northeast, towns are dealing with catastrophic flooding from summer thunderstorms.

“If you look at the whole U.S., the amount of precipitation overall may be less, but it’s delivered in these very intense precipitation events,” explains Brenda Ekwurzel, an author of the report and senior climate scientist at the Union of Concerned Scientists. “That’s how you get a lot of flash flooding, especially after a wildfire.”

In the Southwest, climate change is driving a particularly devious phenomenon: climate change is contributing to drought and flooding in the same place. Drought takes hold for months. When rain does fall, it’s increasingly likely to come as an extreme rainstorm, which causes flash flooding and landslides. Scientists predict that dynamic will only get worse as climate change progresses.

The report’s authors also focus multiple chapters on the health effects of climate change. In a section on air pollution, they write:

“Unless counteracting efforts to improve air quality are implemented, climate change will worsen existing air pollution levels. This worsened air pollution would increase the incidence of adverse respiratory and cardiovascular health effects, including premature death.”

And as the climate warms, disease-carrying insects such as mosquitoes and ticks are also expected to expand their territory.

The authors warn that those who are most economically and physically vulnerable will continue to be most severely impacted by climate change, whether it’s air pollution, disease, floods or fire disasters.

Climate adaptation is already taking place at the local, state and regional level, the report says. It gives examples including water conservation, forest management, infrastructure updates and agricultural advances.

“The real leading edge of action in the United States, now, to deal with climate change is at the non-federal level,” says Light, who also serves as a senior fellow at the World Resources Institute think tank. “It states, it’s cities, it’s businesses.”

But far more involvement is needed on all levels to change human behavior.

“Successful adaptation has been hindered by the assumption that climate conditions are and will be similar to those in the past,” the authors write, arguing that acknowledging climate change, adapting to its effects and working to limit global warming, while expensive, will save money and lives in the long term.

Those findings are in stark contrast to policies put forward by the Trump administration, which include announcing that the U.S. intends to withdraw from the 2015 Paris climate agreement, which set international targets for reducing greenhouse gas emissions.

While the new report does not make policy recommendations, it is designed to be a scientific resource for leaders at all levels of government.

“We’re putting a cost on inaction,” explains Ekwurzel, referring to future global inaction to significantly reduce greenhouse gas emissions and adapt to the effects of climate change. “There’s some really heavy duty news in here. I mean, we’re talking billions of dollars as the cost of inaction each year. I think a lot of people in the U.S. will be surprised by that.”

Study uncovers the link between air pollution and intellectual disabilities in children

The journal Wiley reported that British children with intellectual disabilities are more likely than their peers to live in areas with high outdoor air pollution, according to a new Journal of Intellectual Disability Research study funded by Public Health England.

The findings come from an analysis of data extracted from the UK’s Millennium Cohort Study, a nationally representative sample of more than 18,000 UK children born from 2000 to 2002.

Averaging across ages, children with intellectual disabilities were 33 percent more likely to live in areas with high levels of diesel particulate matter, 30 percent more likely to live in areas with high levels of nitrogen dioxide, 30 percent more likely to live in areas with high levels of carbon monoxide, and 17 percent more likely to live in areas with high levels of sulphur dioxide.

The authors note that intellectual disability is more common among children living in more socioeconomically deprived areas, which tend to have higher levels of air pollution; however, exposure to outdoor air pollution may impede cognitive development, thereby increasing the risk of intellectual disability.

“We know that people with intellectual disabilities in the UK have poorer health and die earlier than they should. This research adds another piece to the jigsaw of understanding why that is the case and what needs to be done about it,” said lead author Dr. Eric Emerson, of The University of Sydney, in Australia.

So, whether you believe in climate change and its relationship to the wildfires in California the extent of the fires, what we are seeing now with the physical damage is just the beginning.

Finally, after my post on gun control look at this news report: Milwaukee Girl Who Condemned Gun Violence Is Killed By Bullet

Jessica Reedy wrote that two years ago when sixth-grader Sandra Parks was at Milwaukee’s Keefe Avenue School, she wrote an essay about gun violence:

“We are in a state of chaos. In the city in which I live, I hear and see examples of chaos almost every day. Little children are victims of senseless gun violence. There is too much black on black crime. As an African-American, that makes me feel depressed. Many people have lost faith in America and its ability to be a living example of Dr. King’s dream!”

The essay titled “Our Truth” took third place in Milwaukee Public School’s annual Martin Luther King Jr. essay contest. In January 2017, Sandra told Wisconsin Public Radio, “All you hear about is somebody dying and somebody getting shot. People do not just think about whose father or son or granddaughter or grandson was just killed.”

She also said she looked forward to doing big things in her life. “I would like to stop all the violence and… negativity that’s going on in the world,” she said. “And stop all the black on black crimes, and all the rumors and stereotypes that’s been spread around.”

How horrible an outcome for this sixth-grade girl and just for her condemnation of gun violence!

Where are we going as a society?