Category Archives: healthcare delivery

Whistleblower Alleges Fraud At A Large Medicare Advantage Plan In Seattle and on and on about the last Democrat Debate and more on Medicare for All

72488737_2301802426616070_6529440653267435520_nWhat a unique world we live in. Bernie Sanders, a man running for the position of President, ignores his symptoms of heart disease, has a heart attack, needs stents for his coronary arteries which are obstructed and a few weeks later is back on the difficult road to running for President. What a jerk who I am sure is ignoring his doctor’s advice, who I’m sure has discussed his post-procedure heart disease restrictions including taking stress, etc. easy for at least 6 weeks, or that what is what I would tell my patient. And this is the man who is telling us all how we should all be deciding our health care system. Unbelievable!! Now, with all the whistleblowers coming out of the woodworks, Fred Schulte points out another whistleblower. Group Health Cooperative in Seattle, one of the United States’ oldest and most respected nonprofit health insurance plans, is accused of bilking Medicare out of millions of dollars in a federal whistleblower case.

Teresa Ross, a former medical billing manager at the insurer, alleges that it sought to reverse financial losses in 2010 by claiming that some patients were sicker than they were or by billing for medical conditions that patients didn’t actually have. As a result, the insurer retroactively collected an estimated $8 million from Medicare for 2010 services, according to the suit.

Ross filed suit in federal court in Buffalo, N.Y., in 2012, but the suit remained under a court seal until July and is in its initial stages. The suit also names as defendants two medical coding consultants — consulting firm DxID of East Rochester, N.Y., and Independent Health Association, an affiliated health plan in Buffalo, N.Y. All denied wrongdoing in separate court motions filed late Wednesday to dismiss the suit.

The Justice Department has thus far declined to take over the case but said in a June 21 court filing that “an active investigation is ongoing.”

The whistleblower suit is one of at least 18 such cases documented by Kaiser Health News that accuses Medicare Advantage managed care plans of ripping off the government by exaggerating how sick their patients were. The whistleblower cases have emerged as a primary tool for clawing back overpayments. While many of the cases are pending in courts, five have recovered a total of nearly $360 million.

“The fraudulent practices described in this complaint are a product of the belief, common among [Medicare Advantage] organizations, that the law can be violated without meaningful consequence,” Ross alleges.

Medicare Advantage plans are a privately run alternative to traditional Medicare that often offers extra benefits such as dental and vision coverage but limits the choice of medical providers. They have exploded in popularity in recent years, enrolling more than 22 million people, just over 1 in 3 of those eligible for Medicare.

Word of another whistleblower alleging Medicare Advantage billing fraud comes as the White House is pushing to expand enrollment in the plans. On Oct. 3, President Trump issued an executive order that permits the plans to offer a range of new benefits to attract patients. One, for instance, is partly covering the cost of Apple watches as an inducement.

Group Health opened for business more than seven decades ago and was among the first managed care plans to contract with Medicare. Formed by a coalition of unions, farmers and local activists, the HMO grew from just a few hundred families to more than 600,000 patients before its members agreed to join California-based Kaiser Permanente. That happened in early 2017, and the plan is now called the Kaiser Foundation Health Plan of Washington. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In an emailed statement, a Kaiser Permanente spokesperson said: “We believe that Group Health complied with the law by submitting its data in good faith, relying on the recommendations of the vendor as well as communications with the federal government, which has not intervened in the case at this time.” Ross nods to the plan’s history, saying it has “traditionally catered to the public interest, often highlighting its efforts to support low-income patients and provide affordable, quality care.”

The insurer’s Medicare Advantage plans “have also traditionally been well regarded, receiving accolades from industry groups and Medicare itself,” according to the suit.

But Ross, who worked at Group Health for more than 14 years in jobs involving billing and coding, says that from 2008 through 2010, the company “went from an operating income of almost $57 million to an operating loss of $60 million.” Ross says the losses were “due largely to poor business decisions by company management.”

The lawsuit alleges that the insurer manipulated a Medicare billing formula known as a risk score. The formula is supposed to pay health plans higher rates for sicker patients, but Medicare estimates that overpayments triggered by inflated risk scores have cost taxpayers $30 billion over the past three years alone.

According to Ross, a Group Health executive in 2011 attended a meeting of the Alliance of Community Health Plans, where he heard from a colleague at Independent Health about an “exciting opportunity” to increase risk scores and revenue. The colleague said Independent Health “had made a lot of money” using its consulting company, which specializes in combing patient charts to find overlooked diseases that health plans can bill for retroactively.

In November 2011, Group Health hired the firm DxID to review medical charts for 2010. The review resulted in $12 million in new claims, according to the suit. Under the deal, DxID took a percentage of the claims revenue it generated, which came to about $1.5 million that year, the suit says.

Ross says she and a doctor who later reviewed the charts found “systematic” problems with the firm’s coding practices. In one case, the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.” Overall, about three-quarters of its claims for higher charges in 2010 were not justified, according to the suit. Ross estimated that the consultants submitted some $35 million in new claims to Medicare on behalf of Group Health for 2010 and 2011.

In its motion to dismiss Ross’ case, Group Health called the matter a “difference of opinion between her allegedly ‘conservative’ method for evaluating the underlying documentation for certain medical conditions and her perception of an ‘aggressive’ approach taken by Defendants.”

Independent Health and the DxID consultants took a similar position in their court motion, arguing that Ross “seeks to manufacture a fraud case out of an honest disagreement about the meaning and applicability of unclear, complex, and often conflicting industry-wide coding criteria.”

In a statement, Independent Health spokesman Frank Sava added: “We believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately.”

Whistleblowers sue on behalf of the federal government and can share in any money recovered. Typically, the cases remain under a court seal for years while the Justice Department investigates.

How would Warren pay for ‘Medicare for All’? Enough evasion, it’s past time for answers.

Chris Truax points out that the last 2 months al anyone who watches the politicians suggesting that Medicare for all is the solution to the healthcare crisis has bombarded the news. Medicare for All will create winners and losers. It’s all very well to say you can’t make an omelet without breaking some eggs unless you’re the egg.

When it comes to doing things, Elizabeth Warren has a plan for everything — and she’s happy to tell you all about it. But when it comes to paying for things, I’m sorry to say, the Massachusetts senator dodges and deflects like a Donald Trump defender.

It’s estimated that “Medicare for All” will cost the federal government an extra $3 trillion a year. That’s more than $9,000 annually from every man, woman, and child in America. Despite being asked, again and again, Warren refuses to acknowledge that paying for this is going to require an across-the-board tax increase — and a pretty massive one, at that. Instead, she keeps talking about how “costs” will go down before she changes the subject to how stressful it is to have your insurance canceled when you get sick or when you have to cope with your mom having diabetes. That’s very true, I’m sure. But we’re talking fiscal policy here.

Warren To Release Plan To Pay For ‘Medicare For All’

Yuval Rosenberg of The Fiscal Times noted that now, just last week Massachusetts Sen. Elizabeth Warren said Sunday she will roll out a plan to pay for an expansive single-payer health care system in the coming weeks, promising the plan would decrease overall costs for the middle class.

“I plan over the next few weeks to put out a plan that talks, specifically, about the cost of ‘Medicare for All’ and how we pay for it,” Warren said at the end of a town hall here at Simpson College. “I will not sign a bill into law that does not reduce the cost of health care for middle-class families.”

Warren’s aides have long suggested she was studying ways to pay for the health care plan originally backed by Vermont Sen. Bernie Sanders, one of her leading rivals for the 2020 Democratic presidential nomination. In recent days, Warren has faced criticism from lower-profile candidates in the race — especially South Bend, Indiana, Mayor Pete Buttigieg and Minnesota Sen. Amy Klobuchar — for her failure to explain how she would pay for the ambitious plan, which would replace private health insurance with generous, universal coverage paid for by the federal government.

“Everybody who is running for president right now knows that families are getting crushed by the high cost of health care,” Warren told the crowd of nearly 500 people. “They also know that the cheapest possible way to make sure that everyone gets the health care that they need is Medicare for All.”

Warren’s statement came after her standard 40-minute stump speech and three questions from attendees, none of whom asked about Medicare for All. The addition appeared to be an attempt to short-circuit recent criticisms of her health care plan.

Warren has previously promised, most recently at the Oct. 15 debate, that no middle-class family would see an increase in overall health care costs. And her aides have said since at least September that she was evaluating ways to pay for Medicare for All. She does not plan to significantly alter the details of the legislation she’s co-sponsored with Sanders in the way Sen. Kamala Harris (D-Calif.) did with her own health care proposal over the summer. Warren said she had been working on the problem of how to pay for the legislation for “months and months.”

“It’s just a little more work until it’s finished,” she said.

For a campaign that has long prided itself on detailed policy proposals, releasing a plan to pay for Medicare for All — which is sure to generate intense scrutiny from the media and her rivals for the nomination — is a high-risk but likely necessary move. Whether or not a plan for Medicare for All would lower costs for the middle class would rely heavily on complicated details, including how progressive the tax system supporting the plan is and how aggressively the government is able to control the cost of health care.

Estimates of how much the plan would cost vary wildly, as do estimates of how much switching to a single-payer system would increase or decrease overall health care costs.

Buttigieg, in particular, has aggressively questioned how Warren would pay for the plan, and said she is being dishonest by not saying whether or not taxes would go up for middle-class families. Sanders has said taxes would likely go up, while overall costs would drop. But Warren has resisted the question, arguing that admitting taxes would rise is equal to accepting a dishonest Republican framing of the issue. Warren has also attacked Buttigieg’s plan for failing to cover every American, dubbing it “Medicare for all who can afford it.”

“Your signature, Senator, is to have a plan for everything. Except this,” Buttigieg said at the debate. “No plan has been laid out to explain how a multi-trillion-dollar hole in this Medicare for All plan that Senator Warren is putting forward.”

Soon, Buttigieg will get his answer.

She ended your last weekend rally asking the “people” to give her a little more time and she will announce how she proposes to pay for it. More important, is her plan, probably an increase of taxes for all, including Middle Americans, to pay for it…. realistic???? Remember, nothing in any of the political “experts” proposals are ever free. Someone, you and I, have to pay for it in some way or another!!

Winners and losers in Medicare for All

There’s a very unpleasant collectivist feel to this. It’s all very well to say you can’t make an omelet without breaking some eggs … unless you’re the egg. About 56% of Americans — more than 180 million — have private health insurance through an employer. Medicare for All would sweep that all away, whether the people who have that insurance like it or not, in the name of the common good. Perhaps worse, as Warren knows perfectly well but steadfastly refuses to admit, there are going to be winners and losers. Costs might go down in the aggregate, but individuals and families aren’t aggregates.

Elizabeth Warren’s choice: ‘Medicare for All’ purity or a path to beating Trump?

For example, Warren keeps saying that the total you pay for health care would end up being less under Medicare for All because it will eliminate out-of-pocket costs like premiums and copays. That’s an oversimplification at best, especially since she hasn’t said how she would finance this enormously expensive project.

But it is a given that everyone will pay higher taxes, and it’s older people who spend more on premiums and out-of-pocket health care costs — a lot more. Consequently, older people will be far more likely to see these higher taxes offset by a decrease in the cost of their health care. By contrast, younger people and families at healthier stages of their lives would still be paying new taxes but will see fewer benefits.

 Your Two-Minute Summary of Tuesday’s Democratic Medicare-for-All Debate

Tuesday night’s Democratic presidential debate once again highlighted the candidate’s deep divides over Medicare for All. After opening questions related to the House impeachment inquiry into President Trump, the debate quickly turned to the health care reform plan backed by Senators Elizabeth Warren and Bernie Sanders.

Warren again tried to reframe the question of whether she would raise middle-class taxes to pay for the plan. “Costs will go up for the wealthy. They will go up for big corporations. And for middle-class families, they will go down,” she said. “I will not sign a bill into law that does not lower costs for middle-class families.”

Pete Buttigieg, who last month called Warren “extremely evasive” on the tax question, pounced. “No plan has been laid out to explain how a multi-trillion-dollar hole in this Medicare for all plan that Senator Warren is putting forward is supposed to get filled in,” he said, touting his “Medicare for All Who Want It” proposal as a better alternative. “I don’t understand why you believe the only way to deliver affordable coverage to everybody is to obliterate private plans, kicking 150 million Americans off of their insurance in four short years,” he said to Warren. “Why unnecessarily divide this country over health care when there’s a better way to deliver coverage for all?”

Warren jabbed back at Buttigieg, saying his “Medicare for All Who Want It” plan is really “Medicare for All Who Can Afford It.”

Joe Biden and Amy Klobuchar, both of whom support building on the Affordable Care Act with a public option, also attacked Medicare for All as expensive and impractical. “The difference between a plan and a pipe dream is something that you can actually get done,” Klobuchar said. “And we can get this public option done.”

Sanders defended his plan — and opened the door for further attacks on Warren. “At the end of the day, the overwhelming majority of people will save money on their health care bills,” Sanders said. “But I do think it is appropriate to acknowledge that taxes will go up. They’re going to go up significantly for the wealthy. And for virtually everybody, the tax increase they pay will be substantially less than what they were paying for premiums and out-of-pocket expenses.”

Klobuchar took the opportunity to criticize Warren again. “At least Bernie is being honest here, and saying how he’s going to pay for this and that taxes are going to go up,” she said. “And I’m sorry, Elizabeth, but you have not said that, and I think we owe the American people to tell them where we will send the invoice.”

A political strategy: The attacks on Warren are widely seen as a sign that she’s now the Democratic frontrunner — and they’re likely a sign that, as tiresome as the repeated tax question might get, Warren is going to keep getting asked it by the media, Democratic rivals, and Republicans. She’s pointedly not willing to answer directly (or take the bait) and say that she will raise taxes, even as she continues to argue that overall costs under Medicare for All will go down for the middle class. Her caginess on the question suggests she thinks that higher taxes on the middle class, or the very word “taxes,” might be toxic in an election campaign against Trump. But her dodging hasn’t hurt her so far.

What the polls say: The latest Kaiser Family Foundation tracking poll found that 51% of those surveyed favor Medicare for All, while 47% oppose it. A majority of Democrats and about half of independents support a national Medicare-for-all plan, while more than 70% of Republicans oppose the idea. Support for a public option is higher, at 73%. A CBS News poll released Tuesday found that 59% of voters believe that a government-run plan should “compete with private insurance” as under a public option, while 32% said they would want it to replace private insurance. But polls have also found that support for Medicare for All or other health plans can shift significantly depending on the arguments presented.

The bottom line: Larry Levitt of the Kaiser Family Foundation reminds us that there is no simple answer to the question of ultimate costs, and that a wide variety of outcomes are possible depending on how Medicare for All is implemented. “A Medicare for all plan could be designed so that many people, including those who are middle class, pay less in taxes than they are paying now in premiums, deductibles, and copays,” Levitt tweeted Tuesday. “It depends entirely on the details.”

J&J Pulls Baby Powder From Market

FDA testing reveals chrysotile fibers in one lot of embattled product of the J&J babypowder, which the courts are suggested cause ovarian cancer.

John Gever the managing editor of the MedPage reported that Johnson  & Johnson is recalling one lot of its famous baby powder because of possible asbestos contamination, the FDA announced Friday.

“FDA testing has found that a sample from one lot of the product contains chrysotile fibers, a type of asbestos,” the agency said in a press release. “Consumers who have Johnson’s Baby Powder lot #22318RB should stop using it immediately and contact Johnson & Johnson for a refund.”

Although Johnson & Johnson agreed to initiate the recall, it stopped short of admitting that the product really was contaminated. It questioned “the integrity of the tested sample and the validity of the test results,” suggesting that it might not even be a genuine Johnson & Johnson product.

The company has consistently denied that its baby powder — on the market for more than a century — has ever been contaminated with asbestos, but the company has faced numerous lawsuits from consumers alleging that they or loved ones developed cancer because of asbestos in talc components. The baby powder is popular not only for use on babies; many women have used it to reduce “feminine odors” as well.

The FDA said it has tested some 50 cosmetic products since 2018 for asbestos contamination, including two lots of Johnson’s Baby Powder. One was negative and the other was positive. This lot of baby powder is not the first to test positive and the FDA has previously issued alerts on others.

“The FDA expects to issue the full results from this survey, including all tested products having both positive and negative results, by the end of the year,” the agency said.

 

Rise in health uninsured may be linked to immigrants’ fears but still they get free health care. Health care cost without insurance and another medical school offers free tuition!

hydrant442[3418]As I caught a ride from the San Diego airport to my hotel in Little Italy, I heard my driver relate to me her and her family’s woes regarding health care. She and her husband were planning of leaving California just as soon as their youngest son finished high school. And they were very tired of the ever-increasing taxes and fees. She was most annoyed that the illegal immigrant families would get free health care and her husband and she can’t afford basic health care. But they have found a way to use urgent care clinics to cover their needs. Alonso-Zaldivar noted that when the Census Bureau reported an increase in the number of people without health insurance in America, it sent political partisans reaching for talking points on the Obama-era health law and its travails. But the new numbers suggest that fears of the Trump administration’s immigration crackdown may be a more significant factor in the slippage.
Overall, the number of uninsured in the U.S. rose by 1.9 million people in 2018, the agency reports this past week. It was the first jump in nearly a decade. An estimated 27.5 million people, or 8.5% of the population, lacked coverage the entire year. Such increases are considered unusual in a strong economy.
The report showed that a drop in low-income people enrolled in Medicaid was the most significant factor behind the higher number of uninsured people.
Hispanics were the only major racial and ethnic category with a significant increase in their uninsured rate. It rose by 1.6 percentage points in 2018, with nearly 18% lacking coverage. There was no significant change in health insurance for non-Hispanic whites, blacks and Asians.
“Some of the biggest declines in coverage are coming among Latinos and noncitizens,” said Larry Levitt of the nonpartisan Kaiser Family Foundation, who tracks trends in health insurance coverage. “These declines in coverage are coming at a time when the Trump administration has tried to curb immigration and discourage immigrants from using public benefits like Medicaid.”
Health care is the defining issue for Democrats vying for their party’s 2020 presidential nomination. Candidates wasted no time in Thursday’s debate highlighting the split between progressives such as Sens. Bernie Sanders and Elizabeth Warren , who favor a government-run system for all, including people without legal permission to be in the country, and moderates like former Vice President Joe Biden. He supports building on the Affordable Care Act and adding a new public plan option, open to U.S. citizens and legal residents.
Although the candidates did not dwell on the uninsured rate, Democratic congressional leaders have said the census figures show the administration’s “sabotage” of the Obama health law.
The administration issued a statement blaming the law’s high premiums, unaffordable for solid middle-class people who do not qualify for financial assistance. “The reality is we will continue to see the number of uninsured increase until we address the underlying issues in Obamacare that have failed the American people,” the statement said.
While the report found an increase in the uninsured rate among solid middle-class people the Trump administration wants to help, there was no significant change in employer coverage or in plans that consumers purchase directly. Those are the types of health insurance that middle-class workers tend to have. Other patterns in the data pointed to an immigration link.
Health economist Richard Frank of Harvard Medical School said the data “suggest that we are dealing with immigration health care crisis potentially in some unexpected ways.” Frank was a high-ranking health policy adviser in the Obama administration.
The uninsured rate for foreign-born people, including those who have become U.S. citizens, also rose significantly, mirroring the shift among Hispanics.
Frank noted that immigrant families often include foreign-born and native-born relatives, “and you can imagine the new approach to immigration inhibiting these people from doing things that would make them more visible to public authorities,” such as applying for government health care programs.
Immigrants’ fears may also be part of the reason for a significant increase in the number of uninsured children in 2018, said Katherine Hempstead, a senior health policy expert with the nonpartisan Robert Wood Johnson Foundation, which works to expand coverage. Among immigrant children who have become citizens, the uninsured rate rose by 2.2 percentage points in 2018, to 8.6%. The increase was greater among kids who are not citizens.
“There are a lot of kids eligible for public coverage but not enrolled because of various things that make it less comfortable for people to enroll in public coverage,” said Hempstead.
The administration’s “public charge” regulation, which could deny green cards to migrants who use government benefits such as Medicaid was finalized this year. But other efforts to restrict immigration, including family separations at the U.S.-Mexico border, were occurring in the period covered by the report.
“People are interpreting ‘public charge’ broadly and even though their kids are eligible for Medicaid because they were born in this country, they are staying away,” said Hempstead. Children’s coverage often follows their parents’ status.
Other factors could also be affecting the numbers:
—The report found a statistically significant increase in solid middle-class people who are uninsured. Health care researcher and consultant Brian Blase, who until recently served as a White House adviser, said it appears to reflect people who cannot afford high ACA premiums. Blase said Trump policies rolled out last year should provide better options for this group. The changes include short-term health insurance plans, health reimbursement accounts and association health plans.
—Experts are debating the impact of a strong job market on the decline in Medicaid enrollment. It’s possible that some Medicaid recipients took jobs that boosted their earnings, making them ineligible for benefits. But if those jobs did not provide health benefits, then the workers would become uninsured. The Census Bureau report showed no significant change in workplace coverage.
Physicians Struggle to Care for Migrants on U.S.-Mexico Border
Elizabeth Hlavinka, Staff writer for MedPage spoke with physicians providing care to migrants in border cities and points out the experiences of providers in El Paso Texas. These stories are evidence of the increasing health care problem facing the migrants and the health care workers attempting to care for the large population.One was the experience of a 17-year-old girl who came into his clinic dizzy, fatigued, and dehydrated, but Carlos Gutierrez, MD, expected that, knowing she’d recently traveled 2,000 miles from Guatemala.
He told her to drink plenty of water to stay hydrated. She had just been released from a detention center and the next part of her journey would begin the following day, traveling east to stay with relatives.
But then she mentioned the diabetes medication she started taking back home, which she stopped before starting her trip.
Alarmed she would go into diabetic ketoacidosis without insulin, Gutierrez checked her blood sugar. It was 700 mg/dL, enough to send her into a coma or worse if she went any longer without treatment.
“It just goes to show that if you had adequate personnel, something like that should have been picked up,” Gutierrez told MedPage Today. “How can you ignore this condition that is deadly if you don’t treat it aggressively?”
Many doctors and healthcare providers have been drawn in by the border crisis, hoping to provide relief to patients in need. Although recent immigration policies have led to dwindling numbers of refugees in the U.S., federal detention center deaths have been reported, and physicians in El Paso contacted by MedPage Today described troubling cases in which medical care was lacking.
The Guatemalan teenager is one of hundreds of patients Gutierrez has seen as a volunteer for Annunciation House, a non-profit organization in El Paso that provides hospitality services to migrants released from detention who are seeking asylum.
There was also the 10-year-old child with congenital adrenal hyperplasia who’d gone without hydrocortisone for a week, and dozens of adults have presented with blood pressure readings upwards of 200/120 mm Hg as a result of not having their hypertension medication, Gutierrez said.
Why Care Goes Awry?
When migrants crossing the border are apprehended by Customs and Border Protection (CBP), their belongings — including belts, shoelaces, and medication — are confiscated. Migrants are not intended to stay in CBP custody for more than 72 hours, just enough time to allow for initial processing before they are transferred to detention centers run by Immigration and Customs Enforcement (ICE).
All ICE detainees then undergo an initial screening, and those whose medications have been confiscated can be issued new prescriptions, an ICE official told MedPage Today. They also get a comprehensive physical exam within two weeks of arrival, and their belongings are returned to them upon release, he said.
But parts of a medical history can be lost in translation if migrants speak less common native languages and are relying on a child as a translator. In other situations, migrants could be released before they get their medication, causing them to go days without it.
Ramon Villaverde, a medical student and Annunciation House volunteer, said migrants may also withhold medical information for fear that revealing health conditions could keep them in detention longer.
“There is this thing looming over their heads, an uncertainty, and because of this uncertainty they might not be comfortable enough to approach these physicians under the facilities,” Villaverde told MedPage Today. “That’s one of the most significant obstacles to providing care.”
An ICE official told MedPage Today that their detention centers staff registered nurses, mental health providers, physician assistants, nurse practitioners, and a physician. There are currently about 200 contract medical providers at CBP facilities, a spokesperson said.
One July job posting for an ICE physician got widespread media attention for stating applicants should be “philosophically committed to the objectives of the facility,” and required physicians to sign nondisclosure agreements upon hiring.
Challenges to Continuity of Care
ICE is required to keep medical records that can be made available to outside healthcare providers once migrants are released, but physicians treating migrants who have been released from detention say they struggle to communicate with providers operating within facility walls.
As a result, patient handoffs are far from seamless, said José Manuel de la Rosa, MD, who also volunteers with Annunciation House, specifically when providers don’t communicate about medications that are needed.
“We’re set up to provide medication to migrants, but we don’t hear about [the need] until they’ve been off medication for two or three days and are beginning to get ill,” he said. “That kind of access to the centers would really help our process.”
As a result, providers are left to gauge what’s happening on the inside, by evaluating the conditions the migrants present with, said Roberto “Bert” Johansson, MD, another Annunciation House volunteer.
Lisa Ayoub-Rodriguez, MD, a pediatrician at a local hospital, has cared for 20 to 30 children hospitalized while in immigration custody since January.
In the winter months, many came in with respiratory problems, pneumonia, or influenza, all of which were complicated by a state of dehydration, she said.
Others were admitted for prolonged refractory seizures due to missing doses of medication. One child, for example, required combination therapy and came into the hospital with a new filled prescription of one medication, but was missing the other, she said.
Hardest on Children
It’s unclear whether pediatricians are staffed at CBP or ICE facilities, but 130,000 family units have been detained in the 2019 fiscal year to date — more than a 300% increase from the same time period in the previous fiscal year.
Because some illnesses present more subtly in children, EMT-trained personnel or even general practitioners may miss certain conditions upon an initial screening, Johansson said.
For example, last year, two children died from sepsis — one bacterial case and the other stemming from influenza — both of which could have initially presented with symptoms similar to the common cold, he said.
“When you look at both of these cases, there was a failure to recognize what could happen,” Johansson said.
Mark Ward, MD, vice president of the American Academy of Pediatrics Texas Chapter, was permitted to have a planned and supervised visit to two McAllen, Texas, CBP facilities in the Rio Grande Valley in June. He also toured a center run by Catholic Charities that provides care for recently released migrants.
At the non-profit, he came across a 16-month-old girl with congenital heart problems who had recently been released from detention with her mother. But her condition had been missed in the screening, such that by the time she arrived at the shelter, she was having heart failure and had to be taken to the ICU.
In May, a 10-year-old girl from El Salvador who crossed the border alone in March also had congenital heart defects, and ultimately died after being passed from hand to hand and undergoing a series of complications. She was one of six migrant children to die while in U.S. custody.
“The CBP is a policing agency and they’re not there to take care of children, so it’s not surprising they aren’t capable of doing a great job of it,” Ward told MedPage Today. “Really the focus is, we’ve got children in U.S. custody who have done nothing wrong, and they should be treated well, in a way that doesn’t damage their health.”
Becoming a Silent Problem?
CBP apprehensions along the border peaked in May at 144,255, but those numbers have been decreasing in recent months, with just 64,000 apprehended in August.
In the fall, physician volunteers treated thousands of migrants each day in more than 25 makeshift clinics across El Paso, including rented out rooms in the Sol y Luna hotel. But today, there are two main centers in operation: one known as Casa Oscar Romero and another large, newly converted warehouse called Casa del Refugiado.
Part of the reason there are fewer migrants on this side of the border is the Migrant Protection Protocol or “Remain in Mexico” policy, which was implemented in January. This policy sends individuals who enter the U.S. illegally, as well as certain asylum seekers, back to Mexico to wait for the duration of their immigration proceedings.
As of Sept. 1, some 42,000 people had been returned to Mexico under the policy, including more than 13,000 asylum seekers who were sent to Juárez. Moreover, only a certain number of asylum claims can be taken up in the U.S. per day, a process known as “metering.”
Taken together, these policies have caused the overflow of migrants traveling into the U.S. to pile up on the Mexican side of the border.
“Right now, we’re in the eye of the hurricane,” Johansson said. “Remain in Mexico has reduced the number of immigrants in the U.S., but they’re still there.”
Most recently, the U.S. Supreme Court endorsed another Trump administration restriction that turns away migrants coming from Central American countries, where the vast majority begin their journey, unless they’ve already applied for asylum before entering the U.S.
Ayoub-Rodriguez said she’s concerned that fewer patients in El Paso means more in Mexico who may not have adequate access to care.
“I’m worried that now it’s becoming a silent problem, that people won’t pay attention and the kids will still suffer without the voice,” Ayoub-Rodriguez told MedPage Today. “That’s my biggest fear — that the harm is still happening and we just aren’t seeing it.”

Wait, Health Care Costs HOW Much Without Insurance?!
Alice Oglethorpe reviewed some of the numbers for those having health insurance but is there an advantage? You might think the financial benefit of having health insurance is mostly tied to major moments—your appendix bursts, you break a leg snowboarding, you’re having a baby—but that’s really just the tip of the bill-lowering iceberg.
Having insurance can also help bring down what you have to pay for everyday: things like that flu shot you’ve been meaning to get or the throat culture you need to rule out strep. Ready for the most surprising part? This is true even if you’re nowhere near hitting your deductible and have to pay the entire bill yourself.
The behind-the-scenes sale
Here’s how it works: “Every hospital and doctor’s office has something called a charge master, which is a list of rates they charge for every single procedure,” says David Johnson, CEO of 4 Sight Health, a thought leadership and advisory company based in Chicago. “But those amounts are somewhat made up, and almost nobody pays them.”
That’s because insurance companies negotiate with the hospitals and doctor’s offices in their network to come up with their own lower rates for literally every procedure. It’s why you tend to see a discount on any doctor’s bill you get—even if you’re responsible for the whole thing because you haven’t hit your deductible yet.
One thing to keep in mind: Those discounted rates are only for in-network doctors and hospitals. Even if you have health insurance, you’ll end up paying the higher master charge rate if you go out-of-network.
While the price the insurance company negotiates can vary (they tend to be about half of the charge master cost), one thing tends to be certain: Anyone who doesn’t have insurance is going to end up paying a ton more. “If you don’t have coverage, it defaults to the charge master rate,” says Johnson. It’s no wonder one out of five uninsured people skip treatment because of cost.
Watch your wallet
All of this can add up quickly, even if you aren’t getting anything too major done. While it’s impossible to say what your cost for different procedures would be with insurance (that changes based on everything from where you live and who your insurer is to your deductible and co-insurance rates), here are some of the average charge master rates for common procedures in the U.S., according to an International Federation of Health Plans report:
• MRI: $1,119
• Cataract surgery: $3,530
• Day in the hospital: $5,220
• Giving birth: $10,808
• Appendix removal: $15,930
• Knee replacement: $28,184
Did someone say free?
On top of the discount you get just for having an insurance plan, there are some procedures and visits that are absolutely free if you have insurance. That’s right: They don’t cost a dime. These services fall under the umbrella of preventive care, and after the Affordable Care Act was passed, they became fully covered for anyone with insurance.
Unfortunately, if you don’t have coverage, you’re stuck paying for them. Here’s how much these otherwise-free services might run you:
• Flu shot: This life-saving vaccine will run you about $40 at your local Rite-Aid pharmacy.
• Screenings for diabetes and cholesterol: CityMD, a chain of urgent care facilities in New York, New Jersey, and Washington, offers these services for about $125 to $200, plus additional lab fees.
• Annual wellness visits: On average, this costs $160, according to a John Hopkins study.
• HPV vaccine: You need this shot twice, and it will cost you about $250 each time, according to Planned Parenthood.
• Birth control pills: The monthly packs will add up to $240 to $600 a year.
The bottom line: With the average employer-sponsored plan costing you $119 a month, that $1,400 or so a year will pay for itself in just a few doctor’s visits or prescriptions. And if something serious happens—like a sprained ankle or a suspicious mole your dermatologist wants to remove—you know you’re covered.
Cornell medical school to offer full scholarships for students who qualify for financial aid
Ryan W. Miller a writer for USA Today wanted us to know some positive news regarding progress in the goal for a financial sustainable education system for the education of our physicians. More future doctors at Cornell University’s medical school, just like the program designed at NYU medical school, will graduate debt-free after the university announced Monday that it would eliminate loans for its students who qualify for financial aid.
Weill Cornell Medicine’s new program will replace federal and school loans in students’ financial aid packages with scholarships that cover tuition, housing and other living expenses.
The program is set to begin this academic year, “then every year thereafter in perpetuity,” the school said in a statement.
Multiple donations that total $160 million will fund the new financial aid policy, Cornell said, though additional fundraising will be needed to ensure the program can continue.
“It is with extraordinary pride that we are able to increase our support of medical education for our students, ensuring that we can welcome the voices and talents of those who are passionate about improving human health,” Augustine M.K. Choi, the school’s dean and provost for medical affairs at Cornell University, said in a statement.
Sanders’ student loan plan: What’s different about Bernie Sanders’ student loan plan? It would help more rich people
More than half of Weill Cornell Medicine medical students qualified for financial aid last academic year, the school said. Based in New York City, the institution’s cost of attendance averages $90,000 a year.
First-year students in the Class of 2023 who qualify for aid will have loans replaced by scholarships for the entirety of their education, and returning students will have their loans replaced this year and the years moving forward, Cornell said.
Like most universities, Cornell uses a formula to determine how much students and their families can contribute to the cost of attendance. Only need-based scholarships will be used to meet the remaining amount, the school said.
Students in a joint M.D.-Ph.D. program will receive full tuition and stipends for living expenses from the National Institutes of Health and Weill Cornell Medicine.
Cornell joins a growing list of medical schools that offer similar programs. Last year, as I mentioned, New York University announced all medical students would receive full-tuition scholarships. Columbia University offers a program similar to Cornell’s to replace loans with scholarships. The University of California-Los Angeles offers a full ride for 20% of its students.
Several top universities offer similar loan-free financial aid for undergraduates.
The issue of mounting debt has increasingly plagued medical students. According to the Association of American Medical Colleges, about three-quarters of medical students take out loans for their education, resulting in a median debt level at graduation of about $200,000.
So, we need some way to either pay for the migrant population’ heath care needs, how it would be financed as well as to decide on the best immigration policy for our country!
Also, as I have mentioned before none of this will be accomplished while the parties and the President are at war and the next Presidential election will not settle any of these issues unless we can all work together! At least Bidden is not following the herd with their Medicare for All solution. But what is his solution….Obamacare or a modification of it?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Democrats Want Medicare for All … or Maybe Not

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sanders: Medicare for All means more taxes, better coverage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here’s a look:

THE BLUEPRINT

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

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

That’s for starters.

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

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

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

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

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

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

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

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

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

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

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

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

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

THE POOR AND THE MIDDLE CLASS

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

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

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

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

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

THE COST

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

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

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

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

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

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

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

 

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

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

As the President of the American Medical Association stated:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MEDICARE FOR ALL

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

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

BUILDING ON OBAMACARE

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

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

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

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

THE NEW ENTRANT

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

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

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

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

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

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

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

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

These Are the Health-Care Questions That Matter Most

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Biden v. Harris

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

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

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

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

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

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

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

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

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

How Bold?

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

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

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

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

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

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

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

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

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

More on Medicare

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

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

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

More to Come!

Why Mention Failed Obamacare When Democrats Can Debate Shiny New Medicare-for-All? And More About the Medicare Bill and Its Provisions.

fourth297Reporter Megan McArdle noted that there’s one thing you didn’t hear at the first two Democratic presidential debates unless you were listening carefully to what candidates didn’t say: Obamacare is a failure.

The Affordable Care Act barely came up. What candidates wanted to talk about was Medicare-for-all.

That is nothing short of extraordinary. In 2010, President Barack Obama signed into law the biggest entitlement expansion, and the most significant health-care reform, since the 1960s. You’d think Democrats would be jostling to claim that mantle for themselves. Instead, it was left in a corner, gathering dust, while the candidates moved on to the fashion of the moment.

In fairness, they may have found the garment an uncomfortable fit. The rate of Americans without health-care insurance is now within a percentage point of where it was in the first quarter of 2008, a year before Obama took office. Yet in 2008, the unemployment rate was more than a full percentage point higher than it is now. Given how many people use employer-provided health insurance, the uninsured rate ought to be markedly lower than it was back then.

Overall, the effect of Obamacare seems to be marginal, or perhaps nonexistent.

You can chalk that up to Republican interference since the uninsured rate has risen substantially in the Trump era. But Democrats weren’t really making that argument, perhaps because they realized that a system so vulnerable to Republican interference isn’t really a very good system.

But even before January 2017, Obamacare was failing to deliver on many of its key promises. At its best point, in November 2016, the reduction in the number of the uninsured was less than the architects of Obamacare had expected. And the claims that Obamacare would “bend the cost curve” had proved, let us say, excessively optimistic.

Adjusted for inflation, consumer out-of-pocket expenditures on health care have been roughly flat since 2007. Obamacare didn’t make them go up, but it didn’t really reduce them, either. The rate of growth in health-services spending has risen substantially since 2013 when Obamacare’s main provisions took effect. And since someone has to pay for all that new spending, premiums have also risen at about the same pace as before Obamacare. So much for saving the average American family $2,500 a year!

Meanwhile, the various proposals that were supposed to streamline care and improve incentives have produced fairly underwhelming results. Accountable-care organizations, which aimed to reorient the system around paying for health rather than treatment, have produced, at best, modest benefits. Meanwhile, a much-touted program to reduce hospital readmissions not only failed to save money but may also have led to thousands of unnecessary deaths.

Nine years in, when you total up all the costs and benefits, you end up with . . . a lot of political aggravation for very little progress. No wonder Democrats would rather talk about something else.

And yet, it’s startling that the something else is health care. The U.S. system is a gigantic, expensive mess, but experience indicates that politicians who wade into that mess are apt to emerge covered in toxic sludge, without having made the mess noticeably tidier.

That could be a good argument for Medicare-for-all: The health-care mess has grown so big, so entangled with the detritus from decades of bad policymaking that it can’t be straightened out. The only thing to do is bulldoze the steaming pile of garbage into a hole and start over.

The argument isn’t unreasonable, even if I don’t agree with it. But it is a policy argument, not a political argument. The political argument in favor of launching into another round of health-care reform is, purely and simply, that a certain portion of the Democratic base wants to hear it.

And a fine reason that is in a primary race. But it then comes to the general election, filled with moderate voters who get anxious when people talk about taking away their private health insurance in favor of a government-run program — as Elizabeth Warren (D-Mass.), Bernie Sanders (I-Vt.) and Kamala D. Harris (D-Calif.) have all done. (On Friday, Harris said she misheard a debate question and changed her position, a flip-flop she has tried before.)

More to the point, whatever the merits of Medicare-for-all, the political obstacles to even the comparatively modest reforms of Obamacare very nearly overwhelmed it — and probably cost Democrats their House majority in 2010. And the compromises that Democrats were forced to make to get even that through Congress left them with a badly drafted program that had insufficient popular support — one that was, in other words, almost doomed to fail. At an enormous political cost. It takes either a very brave politician or a very foolish one, to look at the Obamacare debacle and say, “I want to do that again, except much more so.”

Health Care Gets Heated On Night 2 Of The Democratic Presidential Debate

Reporter Shefali Luthra pointed out that on Thursday, the second night of the first Democratic primary debate, 10 presidential hopefuls took the stage and health issues became an early flashpoint. But if you listen to both nights it was embarrassing. These 25 potential candidates could be the answer to the President’s campaign. Some of their ideas are just too expensive and plain dangerous!!

Sen. Bernie Sanders (I-Vt.) opened the debate calling health care a “human right” — which was echoed by several other candidates — and saying “we have to pass a ‘Medicare for All,’ single-payer system” — which was not.

Just as on Wednesday night, moderators asked candidates who would support abolishing private insurance under a single-payer system. Again, only two candidates — this time Sanders and California Sen. Kamala Harris — raised their hands.

Former Vice President Joe Biden also jumped on health care, saying Americans “need to have insurance that is covered, and that they can afford.”

But he offered a different view of how to achieve the goal, saying the fastest way would be to “build on Obamacare. To build on what we did.” He also drew a line in the sand, promising to oppose any Democrat or Republican who tried to take down Obamacare.

Candidates including South Bend, Ind., Mayor Pete Buttigieg, New York Sen. Kristen Gillibrand and Colorado Sen. Michael Bennet offered their takes on universal coverage, each underscoring the importance of a transition from the current system and suggesting that a public option approach, something that would allow people to buy into a program like Medicare, would offer a “glide path” to the ultimate goal of universal coverage. Gillibrand noted that she ran on such a proposal in 2005. (This is true.)

Meanwhile, former Colorado Gov. John Hickenlooper used the issue of Medicare for All to say that it is important to not allow Republicans to paint the Democratic Party as socialist but also to claim his own successes in implementing coverage expansions to reach “near-universal coverage” in Colorado. PolitiFact examined this claim and found it Mostly True.

“You don’t need big government to do big things. I know that because I’m the one person up here who’s actually done the big progressive things everyone else is talking about,” he said.

But still, while candidates were quick to make their differences clear, not all of their claims fully stood up to scrutiny.

Fact-checking some of those remarks.

Sanders: “President Trump, you’re not standing up for working families when you try to throw 32 million people off the health care that they have.”

This is one of Sanders’ favorite lines, but it falls short of giving the full story of the Republican effort to repeal and replace Obamacare. We rated a similar claim Half True.

I’ll write more about half-truths next week.

Scrapping the Affordable Care Act was a key campaign promise for President Donald Trump. In 2017, as the Republican-led Congress struggled to deliver, Trump tweeted “Republicans should just REPEAL failing Obamacare now and work on a new health care plan that will start from a clean slate.”

The Congressional Budget Office estimated that would lead to 32 million more people without insurance by 2026. But some portion of that 32 million would have chosen not to buy insurance due to the end of the individual mandate, which would happen under repeal. (It happened anyway when the 2017 tax law repealed the fine for the individual mandate.)

In the end, the full repeal didn’t happen. Instead, Trump was only able to zero out the fines for people who didn’t have insurance. Coverage has eroded. The latest survey shows about 1.3 million people have lost insurance since Trump took office.

Bennet, meanwhile, used his time to attack Medicare for All on a feasibility standpoint.

Bennet: “Bernie mentioned the taxes that we would have to pay — because of those taxes, Vermont rejected Medicare for All.”

This is true, although it could use some context.

Vermont’s effort to pass a state-based single-payer health plan — which the state legislature approved in 2011 — officially fell flat in December 2014. Financing the plan ultimately would have required an 11.5% payroll tax on all employers, plus raising the income tax by as much as 9.5%. The governor at the time, Democrat Peter Shumlin, declared this politically untenable.

That said, some analysts suggest other political factors may have played a role, too — for instance, the fallout after the state launched its Affordable Care Act health insurance website, which faced technical difficulties.

Nationally, when voters are told Medicare for All could result in higher taxes, support declines.

And a point was made by author Marianne Williamson about the nation’s high burden of chronic disease.

Williamson: “So many Americans have unnecessary chronic illnesses — so many more compared to other countries.”

There is evidence for this, at least for older Americans.

A November 2014 study by the Commonwealth Fund found that 68% of Americans 65 and older had two or more chronic conditions, and an additional 20% had one chronic condition.

No other country studied — the United Kingdom, New Zealand, Sweden, Norway, France, Switzerland, the Netherlands, Germany, Austria or Canada — had a higher rate of older residents with at least two chronic conditions. The percentages ranged from 33% in the United Kingdom to 56% in Canada.

An earlier study published in the journal Health Affairs in 2007 found that “for many of the most costly chronic conditions, diagnosed disease prevalence and treatment rates were higher in the United States than in a sample of European countries in 2004.”

‘Medicare For All’ Is The New Standard For 2020 Democrats

In 2008, single-payer health care was a fringe idea. Now, its opponents are the ones who have to explain themselves.

Jeffrey Young pointed out that the last time there was a competitive race to be the Democratic presidential nominee, in 2008, just one candidate called for the creation of a national, single-payer health care program that would replace the private health insurance system: then-Rep. Dennis Kucinich (D-Ohio).

This time around, “Medicare for All” is the standard against which all the Democratic candidates’ plans are measured. There’s also a very real chance that, for the first time since Harry Truman, Democrats will nominate a presidential candidate who actively supports the creation of a universal, national health care system.

During Kucinich’s long-shot bid against leading contenders like then-Sens. John Edwards (N.C.), Hillary Clinton (N.Y.) and Barack Obama (Ill.), his opponents barely felt the need to counter his single-payer position. It was seen as too much, too fast, too disruptive and too expensive. Edwards, Clinton, and Obama all instead promoted plans reliant on private insurers. In 2010, President Obama enacted those principles in the form of the Affordable Care Act.

That split still exists, with current Democratic presidential hopefuls like Sen. Amy Klobuchar (Minn.) and former Vice President Joe Biden as the proponents of a more cautious, incremental approach to achieving universal coverage and lower health care costs.

But as the two nights of presidential debates between the 2020 candidates illustrated, it’s Sen. Bernie Sanders (I-Vt.) and his sweeping Medicare for All plan that is now the benchmark for progressive health care reform. It’s appropriate, considering that Sanders’ serious challenge to Clinton in 2016 moved the notion of single-payer health care into the Democratic mainstream.

Sen. Elizabeth Warren (Mass.) acknowledged as much in her response to a question about health care on Wednesday: “I’m with Bernie on Medicare for All,” she said.

The case Sanders made for Medicare for All is essentially the same Kucinich made years ago during his presidential campaign, the difference being that Sanders has earned the right to have his ideas taken seriously, and did a lot of the work to force those ideas into the mainstream.

“The function of health care today from the insurance and drug company perspective is not to provide quality care to all in a cost-effective way. The function of the health care system today is to make billions in profits for the insurance companies,” Sanders said Thursday. “We will have Medicare for All when tens of millions of people are prepared to stand up and tell the insurance companies and the drug companies that their say is gone, that health care is a human right, not something to make huge profits on.”

Among the Democratic candidates, Warren, and Sens. Cory Booker (N.J.),  Kirsten Gillibrand (N.Y.) and Kamala Harris (Calif.) are co-sponsors of Sanders’ bill and Reps. Tulsi Gabbard (Hawaii), Tim Ryan (Ohio) and Eric Swalwell (Calif.) are co-sponsors of a similar House bill introduced by Rep. Pramila Jayapal (D-Wash.).

Biden is a leading representative of the other side of this debate, which also is appropriate. The White House in which he served carried out the biggest expansion of the health care safety net since Democratic President Lyndon Johnson’s Great Society initiatives, which included the creation of Medicare and Medicaid.

And while the Affordable Care Act was nowhere near as far-reaching as single-payer would be, the changes it brought created widespread anxiety among those who already had health coverage, a political dynamic that dogged Obama’s White House.

Like other moderates including Sen. Michael Bennet (Colo.), Biden insisted he supported universal coverage even while opposing Sanders’ Medicare for All plan, and suggested another path.

“The quickest, fastest way to do it is built on Obamacare, to build on what we did,” Biden said Thursday, highlighting his preference for a public option that would be available to everyone in lieu of private insurance.

It was Klobuchar who articulated the political argument that replacing the entire current coverage system with a wholly public one would be disruptive. “I am just simply concerned about kicking half of America off of their health insurance in four years, which is what this bill says,” she said Wednesday.

Although just four of the 20 candidates raised their hands when asked if they supported eliminating private health insurance during the two debates ― Sanders, Warren, Harris and New York Mayor Bill de Blasio ― the very fact that this was the question shows how much has changed since Kucinich’s opponents could safely brush off the notion of single-payer without alienating Democratic primary election voters. (Harris later recanted her answer, claiming to have misunderstood the question.)

Medicare for All proponents learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

The question that was seemingly designed to expose the differences in their points of view had the effect of highlighting how much broad agreement there is within the Democratic Party about what to do about high health care costs and people who are uninsured or under-insured.

It’s also a bit of an odd litmus test in the context of other nations’ universal health care programs, which are meant to be the models for plans like Medicare for All. Private insurance even exists as a supplement to public programs in countries like the United Kingdom and Canada.

Even so, while the question of whether private coverage can coexist with broadened public plans in the United States is a genuine sticking point among Democrats, the responses from the candidates who addressed the issue Wednesday and Thursday nights also highlighted their apparently universal conviction that the federal government should play a much larger role in providing health coverage.

In 2008, the top candidates all supported what’s now considered the moderate position, which was some form of government-run public option as an alternative to private insurance. Centrist Democrats in Congress killed that part of the Affordable Care Act, and Obama went along with it. This year, the public option is the bare minimum.

And every Democratic candidate’s proposals are a far, far cry from the policies President Donald Trump and the Republican Party seek, which amount to dramatically reducing access to health care, especially for people with low incomes.

Likewise in contrast to Trump, all 10 Democrats who appeared at Thursday’s debate endorsed allowing undocumented immigrants access to federal health care programs, which would mark a major shift in government policy. Under current law, undocumented immigrants are ineligible for all forms of federal assistance except limited, emergency benefits.

Just nine years ago, the Democrats who wrote the Affordable Care Act included specific provisions denying undocumented immigrants access to the health insurance policies sold on the law’s exchange marketplaces, even if they want to spend their own money on them.

Medicare for All proponents views the reticence of the candidates who haven’t joined their side as a lack of courage. They also learned from the GOP’s relentless attacks on the Affordable Care Act that even incremental change will bring accusations of rampant socialism, so they might as well go for the whole thing.

“There are a lot of politicians who say, ‘Oh, it’s just not possible. We just can’t do it,’” Warren said Wednesday. “What they’re really telling you is they just won’t fight for it.”

Health care may or may not be a determining factor in which of these candidates walks away with the Democratic nomination. Also unknown is whether Democratic voters’ uneven support for Medicare for All will benefit the more moderate candidates, or whether the progressive message of universal health care and better coverage will appeal to primary voters.

Both camps may actually benefit from the public’s vague understanding of what Medicare for All is and what it would do compared to less ambitious approaches like shoring up the Affordable Care Act and adding a public option.

For moderate candidates like Biden, support for greater access to government benefits may be enough to satisfy all but the most ardent single-payer supporters. But voters who are uncertain about the prospect of upending the entire health coverage system with Medicare for All may also be unconcerned about candidates like Sanders because they don’t realize how much change his plan would bring.

The debates didn’t shed much light on the answers to those questions. Voters will get their first chance to weigh in by February when the Iowa caucuses begin and campaign season kicks into high gear.

Remember that last we talked; the Medicare Bill was passed and signed by President Johnson. Next, I reviewed the main provisions starting with Title XVIII, Part A.

Now on to Title XVIII, Part B: Supplementary Medical Insurance (SMI). This provided that all persons over sixty-five were eligible for participation in this program on a voluntary basis, without the requirement that they had earlier paid into the Social Security program. Benefits included physicians’ services at any location and home health services of up to one hundred visits per year. Coverage also included the costs of diagnostic tests, radiotherapy, ambulance services, and various medical supplies and appliances certified as necessary by the patient’s physician. Subscribers were at first required to pay one-half the monthly premium, with the government underwriting the other half. After July 1973 premium increases levied on subscribers were limited to “the percentage by Social Security cash benefits had been increased since the last…premium adjustment.” Each enrollee was subject to a front-end deductible ($50 per year originally, $100 in 1997). After having met this payment, patients were responsible for a coinsurance of 20 percentage of the remaining “reasonable” charges. Limits were set on the amount of psychiatric care and routine physical examinations. Among the exclusions were eye refraction and other preventive services, such as immunizations and hearing aids. The cost of drugs was also totally excluded. Similar financing arrangements as prevailed for Part A coverage were put in place for Part B for the payment of benefits. Premium payments were placed in a trust fund, which made disbursements to private insurance companies—carriers—who reimbursed providers on a “reasonable cost” or, in the case of physicians, “reasonable charge” basis. Physicians were permitted to “extra bill” patients if they regarded the fee schedule established by the carriers as insufficient payment. (William Shonick, Government and Health Services: Government’s Rule in the Development of U.S. Health Services, 1930-1980, New York, Oxford University Press, 1995. pp 285-91.)

Note that Medicare has further discounted physician fees, which makes it difficult to run a practice based on Medicare reimbursement. We need to remember this when we discuss the new healthcare system, Medicare for All, which almost all of the Democratic presidential candidates propose. Realize also, that not one of those candidates knows anything about Medicare and what Medicare for All really means in its application. Be very careful all you voters!!!

And next on to Title XIX: Medicaid.

And a Happy Fourth of July to All. Remember why we celebrate this day and enjoy our Freedom!

Congress Finally Doing Something: Bundled Billing Won’t Solve Surprise Billing and More About Medicare, Is it Actually Lowering Costs?

57403779_2004991206297195_8128613615025520640_nI stated and I believe that the answer to our healthcare problem has to be a bipartisan solution. Last week Senate health committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) introduced S.1895, the Lower Health Care Costs Act of 2019 — bipartisan legislation to deliver better health care at a lower cost. Chairman Alexander and Ranking Member Murray announced that the committee would vote on the legislation on June 26, 2019.

“The single issue I hear most about from Tennesseans is, ‘What are you going to do about the health care costs I pay for out of my own pocket?’ Well, we’ve got an answer,” said Chairman Alexander. “This legislation will reduce what Americans pay out of their pockets for health care in three major ways: First, it ends surprise billing; second, it creates more transparency — you can’t lower your health care costs until you know what your health care actually costs. And third, it increases prescription drug competition to help bring lower cost generic and biosimilar drugs to patients. I look forward to working with my colleagues in the Senate health committee to mark up this legislation next week before sending it to the full Senate for consideration.”

“People across the country have been facing impossible decisions to afford the care they need and are counting on us to act. So I’m glad my Republican colleagues decided to listen to families and join Democrats at the negotiating table to work on these bipartisan steps to help lower health care costs, end surprise billing, respond to issues like the maternal mortality crisis, vaccine hesitancy, and obesity, and more,” said Senator Murray. “But this must be a first step, not a last one. I hope Republicans will build on this momentum by joining us at the table on bigger health care issues too—like repairing the damage from President Trump’s health care sabotage and protecting people with pre-existing conditions.”

Since last Congress, the Senate health committee has held five hearings on ways to reduce health care costs and four hearings on the cost of prescription drugs. In May, Alexander and Murray released a draft of this legislation for discussion, receiving over 400 comments. The Lower Health Care Costs Act of 2019 is composed of nearly three dozen specific provisions from at least 16 Republican senators and 14 Democrat senators.

Congress is fully engaged in trying to solve “surprise” medical bills and the conversation has exploded into a full-fledged debate on the best way to rein in bad actors while ensuring that physicians receive fair reimbursement for their services. The bipartisan U.S. Senate Working Group on Transparency dropped a new bill in 2019 that aims to address surprise billing. This Working Group, led by Sen. Bill Cassidy, MD (R-LA), has engaged in the most thoughtful discussion on the issue, meeting with stakeholders since summer 2018.

It is no surprise that in May the White House turned to Sen. Cassidy for advice on how to address this issue through legislation. During these discussions, a proposal emerged that would utilize hospital bundled billing to curb unanticipated medical bills. In a letter to the bipartisan Working Group, ASPS and other stakeholders urged the Working Group to consider the full scope of bundling and its ripple effect on patients. This practice would negatively affect patients in rural communities, as bundling could lead to further financial strains on rural and underserved hospitals. Patients may face reduced access to specialty care if hospitals and other facilities are forced to close. The letter highlighted that the use of hospital bundled billing to address this issue is untested and could be highly disruptive to the healthcare delivery system.

Medicare program aimed at lowering costs, improving care may not be working as well as thought

Kara Gavin reported that as the Medicare system seeks to improve the care of older adults while also keeping costs from growing too fast, a new University of Michigan study suggests that one major effort may not be having as much of an impact as hoped.

A new analysis of data from the Medicare Shared Savings Program finds that high-cost physicians and high-cost patients dropping out of the program accounted for much of the savings reported from 2008 to 2014.

After the effects of those departures were taken into account, the Accountable Care Organizations taking part in the MSSP had the same costs as physicians in their area who weren’t taking part in ACOs but also took care of other patients with traditional Medicare coverage.

The study also compares ACO and non-ACO providers on measures of health care quality, finding that patients in an MSSP ACO were not more likely to get four proven tests for common health problems than similar patients with the same kind of Medicare coverage who weren’t part of an ACO.

The study is published in the Annals of Internal Medicine. The authors note that the results have greater implications for providers who voluntarily join an ACO, rather than physicians employed by large group practices that have engaged in Medicare cost and quality efforts for many years—such as those at Michigan Medicine, U-M’s academic medical center.

The findings suggest that as the federal government continues its effort to “bend the cost curve” for Medicare through voluntary reforms, it should take into consideration year-to-year shifts in which providers and patients are taking part in ACOs. Otherwise, the researchers say, “selection bias” could skew the interpretation of the program’s effects.

ACOs can earn extra dollars from Medicare based on their overall costs and quality averaged across all their providers’ patients or can lose money if they don’t meet cost or quality goals. The Centers for Medicare and Medicaid Services has set a goal of increasing the disincentives or “risk” that ACOs face, so accurate measurement of actual cost and quality performance will increase in importance, the researchers say.

“Our results suggest that there is less reason for optimism about the MSSP’s effects to date that might have been suggested by other studies,” said Andy Ryan, senior author of the new study and a professor at the U-M School of Public Health. “We hope CMS will consider the implications as it moves forward with evaluating programs aimed at improving the long-term sustainability of the Medicare system.”

Ryan worked with Adam Markovitz, who led the analysis as part of his doctoral degree in public health and is now completing his medical degree at the U-M Medical School as part of the Medical Scientist Training Program.

“At the project’s outset, we hypothesized that early savings in this voluntary ACO program were driven by the disproportionate entry of high-performing “early adopter” clinicians into ACOs,” Markovitz said. “To our surprise, we found that ACO savings may be driven by the disproportionate exit of higher-spending clinicians out of ACOs.”

In all, the ACO providers whose overall costs were in the top 1% of all providers studied were more than twice as likely to leave an MSSP ACO as providers whose costs fell into the middle level of spending.

Whether these providers were encouraged to leave the ACO because of their costs, or whether they left voluntarily because they were unable or unwilling to reduce the growth in the cost of their patients’ care, can’t be determined through the current study.

MSSP ACO administrators are able to see the costs attributed to each of the providers taking part in their ACO, so “gaming” of which providers to include could be happening, say Ryan and Markovitz.

“We would hope that if a provider shows a trend toward low-value care, the ACO would work with them to remedy the situation,” Ryan said.

Markovitz, Ryan, and colleagues published a study in Health Affairs earlier this year, showing that high-cost patients were slightly more likely to leave ACOs than lower-cost ones. They noted in that study that the MSSP program does not adjust ACOs’ payments depending on how much more ill their participating patients have become over time—the payment is based on how sick each patient was when their provider first joined the ACO.

While this has apparently kept ACOs from “up-coding” patients to game the system, it also means that ACOs may have an incentive to drop providers whose patients become more severely ill—and therefore more costly.

That study and the new study have implications for the changes being proposed for MSSP and other value-based payment programs in Medicare.

“There need to be more safeguards against the selective attrition of patients and providers from ACOs that we’ve observed in our studies,” Ryan said. “As CMS encourages more provider risk-taking, it should design its systems to support what’s working best to improve care and efficiency.”

Markovitz also notes that CMS could design more future Medicare innovations as true experiments—for instance, with randomization (as in Medicare’s bundled payment plan for joint replacement surgery) or a phased roll-out that allows researchers to evaluate more readily whether a program truly saved money or improved quality.

CVS just laid out a big reason why health companies are worried about Amazon

Kyle Walsh of CNBC noted that when word spread that Amazon would move into health care in 2017, health-care executives had a ready answer: We are not afraid.

“I honestly don’t believe that Amazon will be interested in the near future in the next few years in this market,” Walgreens’ CEO Stefano Pessina told investors in an earnings call in July 2017.

“I think we have a lot of capabilities and a value proposition that can compete effectively in the market,” CVS CEO Larry Merlo said back in August.

But recent legal actions tell a different story.

In April, CVS filed a lawsuit against John Lavin, a former senior vice president in charge of CVS Caremark’s retail pharmacy network, after Lavin told the company he was leaving to take a job at Amazon’s pharmacy arm, PillPack. The judge this week ruled in CVS’ favor, preventing Lavin from taking immediate employment at PillPack.

That follows another case from January of this year, where insurance giant UnitedHealth sued one of its employees for attempting to join a different Amazon initiative. That was Haven, Amazon’s joint employer health venture with Berkshire Hathaway and J.P. Morgan.

These lawsuits suggest incumbents are more concerned than they’re letting on in public.

The underlying concern: Amazon going directly to insurers

Amazon has said almost nothing in public about its health-care strategy.

But Amazon could disrupt the space dramatically by negotiating directly with insurance companies on drug pricing, cutting out the existing pharmacy benefits managers, or PBMs. All of that could potentially lower health-care costs for consumers.

Among other functions, PBMs help insurance companies negotiate lower drug costs. Manufacturers arrange discounts, called rebates, with the benefits managers so they can fix a spot for their products on a PBM’s list of preferred drugs. It’s a huge business — CVS’ PBM business represented approximately 60% of its overall revenues in 2018, or around $116 billion, according to a person familiar with CVS’ business.

Amazon PillPack CEO TJ Parker, in a deposition in the Lavin case, admitted to the court that the company had “explored a number of different things.”

But he said the company had “no immediate plans” to compete with CVS Caremark’s core offering, its PBM.

CVS certainly seems to think differently, according to the lawsuit to prevent Lavin from working for PillPack.

“Given its robust infrastructure, operational capacity, and distribution reach, Amazon-PillPack is uniquely positioned to negotiate directly with payers (insurers) and displace CVS Caremark’s email-based services,” CVS argued in support of its motion for a preliminary injunction.

In other words, CVS worries that Amazon is hiring Lavin to approach its clients — insurance plans — for deals that could undercut its PBM.

In particular, CVS said PillPack is already approaching Blue Cross Blue Shield. (CNBC reported talks between PillPack and the insurance network in May.)

“Most recently, Amazon-PillPack engaged in direct discussions with Blue Cross Blue Shield, a federation of 36 health insurance plans that cover more than 100 million Americans, to provide its members with prescription home delivery,” CVS’ motion reads.

Lavin, who has an extensive background working with payers, would be well positioned if Amazon PillPack did decide to take that step toward direct contracting over time.

According to Jefferies’ analyst Brian Tanquilut, who also reviewed the legal documents, there’s a real threat that Amazon could chip away at CVS Caremark’s business over time by going directly to insurers. “The lawsuit shows that pharmacy benefits managers are now also at risk of being dis-intermediated,” he wrote.

To that assertion, a PillPack spokesperson responded: “It is important to keep in mind that what’s being reported here is another company’s speculation about our business strategy for a lawsuit to which neither Amazon nor PillPack is a party.”

However, other drug supply chain experts agree that the PBMs have reason to worry, especially as the health industry consolidates and policymakers are pushing PBMs to be more transparent about their practices.

“PBMs are going to be more protective of their mail pharmacy business than ever and less welcoming to outsiders like PillPack,” said Stephen Buck, a drug supply chain expert who previously worked at McKesson.

For his part, Lavin said in communications to his former employer that he would not be competing head-on with them but would be negotiating from the opposite side of the table.

“I’ll be … handling [PillPack’s] negotiations with PBMs … in other words, it’ll be the opposite of what I did for CVS,” he noted in an email to CVS’ human resources department that was disclosed during the case.

The judge disagreed and granted CVS’ motion to enforce the non-compete agreement and block Lavin from working for PillPack for 18 months.

In his ruling, Judge John J. McConnell wrote, “Mr. Lavin will also negotiate and build relationships with private Payers and public Payers, both of whom are current CVS clients.” McConnell wrote, “It also appears that PillPack will be looking to negotiate directly with the insurers and others on the Payer level.”

CVS, in a statement to CNBC, denied any claim that it is working to block competition and said that it will continue to work with new players.

“We remain focused on delivering innovative solutions to transform the health care experience, but there is always room for new players in health care, as competition can help lower overall costs for payers and patients,” said a spokesperson for CVS Caremark.

If you remember our discussion last week, last we noted was that Wilbur Mills the Chairman of the Ways and Means Committee hit upon the idea of combining the most ambitious components of three of the bills that all of the various groups arguing for a health care solution for the senior population. His idea was quickly embraced by the Administration because they all regarded it as insurance against any Republican attack. On Marci 23, 1965, the Ways and Means Committee voted to substitute the Mill’s bill for the King-Anderson bill and on the following day, it was introduced on the House floor. After only one day of floor debate, the Mill’s bill was passed without amendment by a vote of 313 to 115.

The features of the new bill was incorporated into two amendments to the Social Security Act, which provided in Title 18 for a universal hospital insurance program for the elderly and for optional coverage of physicians’ services while Title 19 (known as Medicaid) expanded the Kerr-Mills program of medical coverage for the needed.

When the Mills bill was referred to the Senate, months of debate and discussion proceeded and then was referred out of committee having been amended no less than seventy-five times.  The full Senate considered further 250 amendments, passed the bill as amended. It was then sent to a Senate-House conference committee with the task to resolve the over 500 differences between the two chambers.

In July the House passed the finally revised bill to be officially part of the Social Security Amendments of 1965 and the next day after the House passed it the Senate approved the measure. Finally, on July 30, 1965, President Johnson flew into Independence Missouri to sign the Medicare bill into law in the presence of former President Truman. Success finally!!

What were the provisions of the legislation?

Title XVIII, Part A: Hospital Insurance provided that all persons over the age of sixty-five otherwise entitled to benefit under the Social Security or Railroad Retirement Act were eligible and were automatically covered. The benefits were measured in sixty-day periods following discharge from a hospital or extended-care facility. During each benefit period, they were entitled to up to ninety days in a hospital, one hundred days in an extended care facility, and home-care benefits for up to one year after the most recent discharge from either a hospital or extended care facility.

Care in either a psychiatric or tuberculosis hospital was limited to a lifetime amount of 190 days, provided that a physician as being “reasonably expected to improve” certified the patient.  Subscribers were required to pay a “front-end deductible” for each hospital stay of up to ninety days. This deductible started at $40 but has risen to more than $760 for the first sixty days and an additional $190 for days 61-90. No front-end deductibles were imposed for the use of extended care facilities for the first twenty days but after that point, a daily copayment was levied.

The program was financed by earmarked payroll taxes levied on employers and employees and disbursements were made from the fund either directly to providers or through an intermediary insurance company who then reimbursed the providers based or what was and still is known as “reasonable costs.”

Because there is a lot more to the bill I will further breakdown the other provisions of the Medicare bill. But as seen in the eventual design and passing of the Medicare bill it took cooperation and bipartisanship to get the job done.

Listen up Congress, no matter which party you belong to!!

More to come.

The Homeless, Illegal Immigrants and Disease: LAPD officers being treated for typhoid fever, typhus-like symptoms. More on Medicare History and the Replacement for the Shortage of Physicians.

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Anthony Rivas reported that at least one officer with the Los Angeles Police Department has contracted the bacteria that causes typhoid fever, Salmonella typhi, and another one is showing typhus-like symptoms, the police department announced on Thursday.

The officer who had contracted the illness is being treated, and the other officer has yet to be confirmed to be infected, according to the LAPD. Both officers work at the LAPD’s Central Division, according to a statement released by the department.

Salmonella Typhi is uncommon in the U.S. and other modern industrialized nations, affecting only about 350 Americans each year — most of whom recently returned from overseas travel. Worldwide, it affects an estimated 22 million people each year, according to the Centers for Disease Control and Prevention (CDC).

The police department is working with the city to “disinfect any work areas that may have been exposed,” a process that is expected to be completed Thursday evening, the LAPD said in a statement.

Salmonella Typhi is commonly spread through food or water that has been contaminated by someone shedding the bacteria. The bacteria can be spread by both people who are actively ill as well as so-called “carriers” of the bacteria but not showing symptoms — one in 20 go on to become carriers. Salmonella typhi is responsible for causing typhoid fever, according to the CDC,.

It’s unclear what caused the officers’ illnesses.

Los Angeles has been dealing with a growing rat infestation and typhus outbreaks since at least October 2018, according to ABC Los Angeles station KABC.

Typhus is different from typhoid fever, which can come from a variety of sources. Murine typhus (Rickettsia typhi) is caused by bites from infected fleas, epidemic typhus (Rickettsia prowazekii) comes from infected body lice and scrub typhus (Orientia tsutsugamushi) comes from infected chiggers or larval mites.

“Unfortunately, our police officers often patrol in adverse environments and can be exposed to various dangerous elements,” the LAPD said in a statement on Thursday. “We have notified the Police Protective League as well as our employees working at Central Division, about the outbreak and we have further provided them with strategies to stay healthy while we mitigate this issue.”

Typhoid fever and typhus are often diagnosed through blood tests and treated with antibiotics. Symptoms associated with the two infections include fever and chills, body and muscle aches, nausea and vomiting.

The best way to prevent infection by Salmonella typhi is to wash your hands frequently, and for any form of typhus, to avoid contact with the animals that can pass on the infection.

I just read an article regarding the future of healthcare and the focus was on Artificial Intelligence, but this next piece is about what we are seeing right now due to the shortage of physicians. This is happening here in the US but also throughout Europe also.

As nurse practitioners fill the gap, patients say they’re more than satisfied with the care

Findings from a new research study led by Thomas Kippenbrock, a nursing professor at the University of Arkansas, suggest that patients are just as satisfied—or even happier—with care from nurse practitioners as compared with doctors.

Kippenbrock wrote an article titled “A National Survey of Nurse Practitioners’ Patient Satisfaction Outcomes” for Nursing Outlook, a bi-monthly journal that examines current issues and trends in nursing practice, education and research. The journal seeks to help solve challenges facing the profession.

Currently, nurse practitioners are helping to fill a gap in providing primary care across the country and especially in the rural communities, which is why it’s important to determine patients’ satisfaction rate.

Kippenbrock and fellow U of A School of Nursing colleagues, Jan Emory and Peggy Lee, gathered feedback from 53,885 patients through the Consumer Assessment of Healthcare Providers and Systems survey, asking them to identify and rate their perceptions of interactions with their health provider.

Using responses to the survey, which was developed by the Agency for Healthcare Research and Quality to advance scientific understanding of the patient care experience, researchers found that patients are reporting equal or greater satisfaction rates with care from nurse practitioners when compared to their physician colleagues. The study notes that Medicaid patients rated nurse practitioners’ communication skills as high as other providers.

“The leap in this study was a large national scale investigation,” Kippenbrock said. “Previous findings were derived from small sample sizes isolated to local community clinics. Consequently, we believe patients are highly satisfied with a nurse practitioners’ primary care services.”

So, what about using barbers as our physicians?

Will Barbers Regain Their Role as Medical Practitioners?

Milton Packer highlighted the rediscovery of a 1,000-year-old cure for medical elitism and maybe physician shortage. For most of human history, people did not see the expertise of a physician in the hope of a cure. Physicians relied on patients’ natural healing processes for recovery. Doctors primarily provided comfort — by the compassionate communication of a diagnosis, often accompanied by the symbolic prescription of herbs and salves. The physician acted as a supportive guide to the unfolding of a natural course of events.

This approach is embodied in the many quotations attributed to Hippocrates. “Natural forces within us are the true healers of disease.” “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” “Cure sometimes, treat often, comfort always.”

But in the first millennium C.E., physicians were in short supply. The talented few lived an elitist existence, typically attached to wealthy or powerful royal families. Famed physicians, such as Galen and Avicenna, were able to formulate ideas and write books because they were supported by wealthy patrons.

Who provided medical care for the common man, especially the poor? With no access to physicians, the poor turned to the clergy, who spent much of their time practicing medicine. Building on existing relationships of trust, priests could attend to someone’s physical and spiritual needs simultaneously. However, the Church believed that spiritual men should not be focused on worldly cares. Thus, during the latter half of the 12th century, it insisted that priests were “expert physicians of souls rather than to cure bodies.” The practice of medicine was strictly forbidden, especially when it required cutting or burning.

So where would a “commoner” go if he/she required some procedural intervention? Barbers — with their expertise with knives and razors — stepped up to fill the need, by offering a wide range of surgical procedures to their customers. On a given day, they might provide a haircut, an amputation, a tooth extraction, or the application of leeches. All of these filled the barbershop with blood and bandages. When wrapped around a pole, they formed a spiral of red and white stripes and voilà! The modern barbershop pole was born. (Barbershop poles in the U.S. added a blue stripe — for patriotic reasons.)

From the 12th century onwards, the expertise and practices of physicians and barbers became distinct, leading to a troubled relationship between the two groups. Physicians who received university training believed they had privileged access to specialized knowledge and felt superior to the barbers, who had no specialized education and treated only commoners. To highlight the distinction, physicians insisted that they wear long robes, while barbers could wear only short robes. The practice of long white coats for physicians and short white jackets for barbers persisted into the late 20th century.

Surgeons eventually differentiated themselves from barbers in the 17th and 18th centuries, but physicians and surgeons remained distinct specialties for several hundred years. When surgeons eventually commingled with physicians at medical schools, they wore long white coats — to emphasize to the world that they were not barbers, but were now part of an elite profession.

The elitism of physicians and surgeons provided great satisfaction to those with a medical degree, but it provided little comfort to patients. From the 1940s through the 1970s, the relationship between doctors and patients was distinctly hierarchical. Physicians presented themselves as the authoritative source of medical knowledge and did not expect to have their recommendations questioned. That is not to say that physicians lacked compassion. Indeed, if a patient could find a knowledgeable and kind medical doctor, the bond between the two was therapeutically powerful. Under these ideal circumstances, physicians could provide both comfort and a cure, and in return, patients provided gratitude and trust. That trust was the centerpiece of the therapeutic relationship.

However, over the past 30 years, much of the trust that grounded the patient-physician relationship has been shattered. Today, physicians often seem determined to spend as little time with patients as possible. The history and physical exam are perfunctory, and questions are frequently swatted away. All too often, physicians seem more interested in generating revenues than listening to patients. In response, admiration for physicians has waned; and patients have become suspicious of physicians’ motives when prescribing medications or recommending procedures. Adherence to medications is abysmally low.

Adherence is particularly problematic when people need to take multiple medications on a daily basis for years for an asymptomatic condition, such as hypertension. Hypertension is an important and treatable cardiovascular risk factor, but it is poorly controlled in the community — particularly in socioeconomically disadvantaged populations, who are particularly susceptible to hypertension and its sequelae and are also often mistrustful of their interactions with the medical profession.

How can this problem be resolved? Dr. Ronald Victor, a hypertension specialist, came up with a brilliant idea. What if we could identify a trusted individual within the underserved community who could be trained to measure blood pressures and provide emotional support for treatment? People would interact with this trusted individual on a regular basis to obtain repeated measurements of blood pressure and reinforce the use of medications.

Ron Victor’s solution was the barbershop. The barbershop plays a central role in the social fabric of black men in underserved communities. Men visit barbershops on a regular basis, and each has a relationship of trust with his barber, established through repeated (and often personal) conversations that transpire during the haircuts. As a result, the barber was perfectly positioned to measure the blood pressure of every client at regular visits and then could immediately connect those with hypertension to specially-trained pharmacists who would prescribe generic medications on site.

Dr. Victor and his colleagues carried out a cluster randomized trial to prove that his idea would work. A total of 319 black male patrons with hypertension were recruited from 52 black-owned barbershops. In half of the barbershops, men were assigned to the barber-pharmacist intervention, and in the other half, barbers simply encouraged lifestyle modification and doctor appointments. After 6 months, a blood-pressure level of less than 130/80 mm Hg was achieved among 64% of the participants in the intervention group versus only 12% of the participants in the control group. A truly dramatic result!

Why did Ron Victor’s idea work? The men paid attention to their blood pressure and took their medications because the treatment was based on a relationship of trust and transpired in a place of trust. By contrast, their hypertension was not controlled if the men were simply reminded to see their physicians.

The historical parallels are striking. About 1,000 years ago, barbers stepped up to provide essential medical care to underserved communities who had no access to academically-trained physicians. Now, barbers are stepping up again as trusted members of the community to link people to essential treatments that they would be reluctant to take if prescribed by a physician.

In many ways, the divide between those who provide care and those who need it has not changed over the past 1,000 years. Ten centuries ago, academically-trained physicians were not interested in treating commoners. In the current era, underserved populations do not trust physicians to care for them, perhaps because they believe that physicians are driven by self-interest. The patterns of disconnect a millennium apart are eerily similar.

I was privileged to know and work with Ron Victor when we were both at the University of Texas Southwestern Medical School (2004-2009). He was an exceptionally talented and heroic physician-scientist, whose brilliance, innovation, compassion, and humility were beyond words.

Ron Victor died in September 2018 in Los Angeles. His contributions to medicine are numerous, but perhaps most importantly, his work reminded us of the clinical and social consequences of medical elitism, for which he provided a path towards rectification. He is sorely missed.

Families list health care as a top financial problem: poll

Tal Axelrod noted that Health care costs are the top financial issue facing most American families, according to a new Gallup poll released Thursday.

About 17 percent of Americans said health care was their most significant financial issue, followed by 11 percent citing lack of money or low wages, 8 percent saying college expenses, 8 percent saying the cost of owning or renting a home and 8 percent saying taxes.

Health care costs were also the most significant financial issue for Americans in 2017 and nearly tied with lack of money or low wages for the top spot in 2018, according to the poll.

Health care costs are most likely to be the top concerns for older Americans, with 25 percent of adults between the ages of 50 and 64, and 23 percent of those aged 65 and older listing them as their top financial problems. Health care costs are tied with lack of money, college expenses and housing costs as the greatest financial worries among adults younger than 50.

Health care also ranked as the top financial concern for Americans among all income levels.

Health care costs, energy costs or oil and gas prices and lack of money or low wages are the only three issues to ever top the “most important family financial problem” question in the 48 times Gallup has asked it since 2005.

However, mentions of energy costs have declined as gas prices have gone down over the last decade.

Reflecting a time of high economic confidence, 20 percent of Americans say they do not have a “most important financial problem,” one of the highest responses to the question in the Gallup poll’s 14 years. That figure was only surpassed in February 2005, when 21 percent of Americans said they do not have a top financial issue.

Despite strong economic numbers, Democrats are likely to highlight health care issues in the 2020 race after focusing on the issue to win back the majority in the House in 2018.

“Even in generally good economic times, Americans still face significant personal financial challenges. Foremost among these are healthcare costs, which have been a consistent concern over time but currently stand above all other concerns. As such, healthcare will likely continue to be a major focus in national elections, including the 2020 presidential election,” Gallup concluded.

Medicare and healthcare reform

So, when did we really make inroads in healthcare reform? Things started to get more positive in 1952 when the President’s Commission on Health Needs of the Nation later that year echoed the Social Security Administration’s annual report recommended enactment of health insurance for social security beneficiaries and the recommendation. However, General Eisenhower, who was to take office made clear that he would not support government health insurance.

Despite the opposition by the Eisenhower administration things began to happen that eventually led to some major changes. In 1956 Congress enacted a permanent program of health care coverage for the dependents of servicemen (what has been described as a military “medicare” program) and at the same time began on the Social Security Act cash benefits to totally and permanently disabled persons over the age of fifty. The AMA opposed the amendment and the battle began between those supporting and opposing this extension of the social security program, which was viewed as a test of strength between physicians and health reformers.

Then when the disability insurance measure passed a Democratic member of the House Ways and Means Committee, Aime J. Forand, introduced a medicare bill just prior to adjournment of the House in late 1957.

Next was the number of public hearings on the bill, which were held in June of 1958 before the House Ways and Means Committee, which proved inconclusive. The number of national groups started lining up on either side of the issue. The AFL-CIO, the National Farmers Union, the Group Health Association of America, the American Nurses Association, the American Public Welfare Association, and the National Association of Social Workers all supported the bill. On the other side, the opponents were the National Chamber of Commerce, the National Association of Manufacturers, the Pharmaceutical Manufacturers’ Association, the American Farm Bureau Association, the Health Insurance Association of America, and of course the AMA.

The fear of government cutting into the sales of insurance contracts as had been the case with government life insurance for servicemen during the First and Second World Wars and also with the passage of social security and its extensions. At the Forand bill hearings, the spokesman estimated the cost of the measure would exceed $2 billion per year, which was a tremendous underestimate.

However, because of the President’s opposition and the controversial nature of the Forand bill, the measure died in committee.  More hearings were held in 1959 with the same result as well as in 1960 where the Forand bill was able to obtain a vote on the bill in Committee with the result of a defeat again.

Despite the defeat after defeat, momentum in support of the proposal seemed to be increasing.

The next and most important stage of this historic saga is the one that brings the most changes and I will continue the discussion starting with House Speaker Sam Rayburn and Senate Majority Leader Lyndon Johnson who both spoke and lobbied in favor of the bill which increased more support. First to come will be medical assistance through the states proposed by Wilbur Mills but not until John F. Kennedy was real progress made.

More next week.