Category Archives: Insurance

Congress Must Pony Up to Improve Nation’s Health, Doc Groups Say and Our Politicians Need to Change the Conversation

52585272_1914340792028904_751869742112833536_nIt was an interesting week on so many levels. I guess that we don’t have to worry about another government shut down…. until next September but now Congress, the Senate and the President will fight and get nothing done… Probably not even getting the full wall.

Can any progress be made on health care if we have all this anger, incivility and progressive socialism?!? Let’s have progress in health care and vows to work for a better future!

Medical society leaders come to Capitol Hill to push their funding priorities

News Editor of MedPage, Joyce Frieden remarked that Congress needs to do a better job of funding public health priorities and improving the healthcare system, a group of six physician organizations told members of Congress.

Presidents of six physician organizations — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and the American Psychiatric Association — visited members of Congress as a group here Wednesday to get their message across. The American Medical Association, whose annual Washington advocacy conference takes place here next week, did not participate.

The physician organizations had a series of principles that they wanted to emphasize during their Capitol Hill visits, including:

  • Helping people maintain their insurance coverage
  • Protecting patient-centered insurance reforms
  • Stabilizing the insurance market
  • Improving the healthcare financing system
  • Addressing high prescription drug prices

The group also released a list of proposed 2020 appropriations for various federal healthcare agencies, including:

  • $8.75 billion for the Health Resources and Services Administration
  • $7.8 billion for the CDC
  • $460 million for the Agency for Healthcare Research and Quality
  • $41.6 billion for the National Institutes of Health
  • $3.7 billion for the Centers for Medicare & Medicaid Services

One of the group’s specific principles revolves around Medicaid funding. “Policymakers should not make changes to federal Medicaid funding that would erode benefits, eligibility, or coverage compared to current law,” the group said in its priorities statement.

This would include programs like the work requirements recently approved in Arkansas and other states; the Kaiser Family Foundation reported in January that more than 18,000 Arkansans have been dropped from the Medicaid rolls for failing to meet the work requirements there.

“Our group is very, very supportive of innovation,” said Ana Maria López, MD, MPH, president of the American College of Physicians, at a breakfast briefing here with reporters. “We welcome testing and evaluation, but we have a very strong tenet that any effort should first do no harm, so any proposed changes should increase — not decrease — the number of people who are insured. Anything that decreases access we should not support.”

That includes work requirements, said John Cullen, MD, president of the American Academy of Family Physicians. “When waivers are used in ways that are trying to get people off of the Medicaid rolls, I think that’s a problem,” he said. “What you want to do is increase coverage.”

Lydia Jeffries, MD, a member of the government affairs committee of the American College of Obstetricians and Gynecologists, agreed. “We support voluntary efforts to increase jobs in the Medicaid population, but we strongly feel that mandatory efforts are against our principal tenets of increasing coverage.”

More $$ for Gun Violence Research

Gun violence research is another focus for the group, which is seeking $50 million in new CDC funding to study firearm-related morbidity and mortality prevention. Kyle Yasuda, MD, president of the American Academy of Pediatrics, explained that gun research stopped in 1997 after the passage of the so-called Dickey Amendment, which prevented the CDC from doing any “gun control advocacy” — that is, accepting for publication obviously biased articles and rejecting any articles that found any positive benefits to gun ownership. Although the amendment didn’t ban the research per se, the CDC chose to comply with it by just avoiding any gun violence research altogether.

Recently, however, Health and Human Services Secretary Alex Azar and CDC Director Robert Redfield, MD, “have provided assurances that the language in the Dickey Amendment would allow for [this] research,” said Yasuda. “We didn’t have research to guide us and that’s what we need to go back to.”

The research is important, said Altha Stewart, MD, president of the American Psychiatric Association, because “in addition to the physical consequences related to gun violence, there’s a long-term psychological impact on everyone involved — both the people who are hurt and the people who witness that hurt. It’s a set of concentric circles that emerges when we talk about the psychological effects of trauma. We often think of [these people] as outliers, but for many people, we work with, this has become all too common in their lives.

“This is definitely our lane as physicians and I’m glad we’re in it,” she said, referring to a popular hashtag on the topic.

Yasuda said the effects of gun violence are nothing new to him because he spent half his career as a trauma surgeon in Seattle. “It’s not just the long-term effect on kids, it is the next generation of kids … It’s the impact on future generations that this exposure to gun violence has on our society, and we just have to stop it.”

The high cost of prescription drugs also needs to be addressed, López said. “We see this every day; people come in and have a list of medications, and you look and see when they were refilled, and see that the refill times are not exactly right … People will say, ‘I can afford to take these two meds on a daily basis, these I have to take once a week’ … They make a plan. [They say] ‘I can fill my meds or I can pay my rent.’ People are making these sorts of choices, and as physicians, it’s our job to advocate for their health.”

One thing the group is staying away from is endorsing a specific health reform plan. “We’re agnostic as far as what a plan looks like, but it has to follow the principles we’ve outlined on consumer protection, coverage, and benefits,” said Cullen. “As far as a specific plan, we have not decided on that.”

Also, Politicians Need To Change The Conversation On How To Fix Health Care

Discussions about Medicare for all, free market care, and Obamacare address one issue – how we pay for health care. The public is tired of these political sound bites and doesn’t have faith in either public or private payment systems to fix their health care woes. Changing the payer system isn’t going to fix the real problem of the underlying cost of care and how it is delivered.

The current system is rotting from the inside. Fee for service payment started the trend with rewarding health care providers for the amount of care they deliver. Through the decades, health care organizations learned how to manipulate the system to maximize profit. Remember, at no time has an insurer lost money. They just increase premiums and decrease reimbursements to health care facilities and caregivers and constrict their coverage. Insurers retaliated by creating more hoops to jump through to get services covered. This includes both Medicare and private insurance.

Who is left to deal with the quagmire? The patients. Additionally, the health care professionals who originally entered their profession to take care of people became burned out minions of the health care machine. Now we are left with an expensive, fragmented health care system that costs three times more than the average costs of other developed countries and has much poorer health outcomes.

Our country needs a fresh conversation on how to fix our health care system. The politicians who can simplify health care delivery and provide a plan to help the most people at a reasonable cost will win the day. There are straightforward fixes to the problem.

Provide taxpayer-funded primary care directly and remove it from insurance coverage

About 75% of the population needs only primary care. Early hypertension, diabetes, and other common chronic issues can be easily cared for by a good primary care system. This will reduce the progression of a disease and reduce costs down the line.  Unfortunately, the fee for service system has decimated our primary care workforce through turf wars and payment disparities with specialty care and we now have a severe primary care shortage. Patients often end up with multiple specialists which increases cost, provides unsafe and fragmented care, and decreases patient productivity.

Insurance is meant to cover only high cost or rare events. Primary care is inexpensive and is needed regularly, so it is not insurable. We pay insurance companies  25% in overhead for the privilege of covering our primary care expenses. Plus, patients and their doctors often must fight insurance companies to get services covered. The lost productivity for patients and care providers is immeasurable.

In a previous article, the author shared the proposal of creating a nationalized network of community health centers to provide free primary care, dental care, and mental health care to everyone in this country.

  • Community health centers currently provide these services for an average cost of less than $1,000 per person per year. By providing this care free to all, we can remove primary care from insurance coverage, which would reduce the cost of health insurance premiums.

Free primary care would improve population health, which will subsequently reduce the cost of specialty care and further reduce premiums.

  • Community health centers can serve as treatment centers for addiction, such as our current opioid crisis, and serve as centers of preparedness for epidemic and bioterrorist events.

People who do not want to access a community health center can pay for primary care through direct primary care providers.

  • This idea is not unprecedented – Spain enacted a nationwide system of community health centers in the 1980s. Health care measures, patient satisfaction, and costs improved significantly.

By providing a free base of primary care, dental care, and mental health care to everyone in this country, we can improve health, reduce costs, and improve productivity while we work toward fixing our health care payment system.

Current Community Health Centers

Community health centers currently serve approximately 25 million low-income patients although they have the structural capacity to serve many more. This historical perspective of serving low-income individuals may be a barrier to acceptance in the wider population. In fact, when discussing this proposal with a number of health economists and policy people, many felt the current variability in the quality of care would discourage use of community health centers in all but a low-income population. Proper funding, a culture of care and accountability, and the creation of a high functioning state of the art facilities would address this concern.

There are currently a number of community health centers offering innovative care, including dental and mental health care. Some centers use group care and community health workers to deliver care to their communities. Many have programs making a serious dent in fighting the opioid epidemic. Taking the best of these high functioning clinics and creating a prototype clinic to serve every community in our nation is the first step in fixing our health care system

The Prototype Community Health Center – Delivery of Care

Community health centers will be built around the patient’s needs. Each clinic should have:

  • Extended and weekend hours to deliver both acute and routine primary care, dental care, and mental health care. This includes reproductive and pediatric care.
  • Home visits using community health workers and telemedicine to reach remote areas, homebound, and vulnerable populations such as the elderly.
  • Community and group-based education programs for preventive health, obesity prevention and treatment, smoking cessation, and management of chronic diseases such as diabetes, hypertension, musculoskeletal problems, chronic pain, asthma, and mental health.
  • A pharmacy that provides generic medications used for common acute and chronic illnesses. Medication will be issued during the patient’s visit.
  • There will be no patient billing. Centers will be paid globally based on the population they serve.

The standard of care will be evidence-based for problems that have evidence-based research available. If patients desire care that is not evidence based, they can access it outside the community health system and pay for that care directly. For problems that do not have evidence-based research, basic standards of care will apply.

It will be very important that both providers and patients understand exactly what services will be delivered. By setting clear expectations and boundaries, efficiency can be maintained and manipulation of the system can be minimized.

The Prototype Community Health Center – Staffing

The clinics would be federally staffed and funded. Health care providers and other employees will receive competitive salary and benefits. To attract primary care providers, school loan repayment plans can be part of the compensation package.

The “culture” of community health centers must be codified and will be an additional attraction for potential employees. A positive culture focused on keeping patients AND staff healthy and happy, open communication, non-defensive problem solving, and an attitude of creating success should be the standard. Bonuses should be based on the quality of care delivery and participation in maintaining good culture.

One nationalized medical record system will be used for all community health centers. The medical records will be built solely for patient care. Clinical decision support systems can be utilized to guide health care providers in standards of diagnosis and treatment, including when to refer outside the system.

Through the use of telemedicine, basic consultation with specialists can be provided but specialists will consult with the primary care physicians directly. One specialist can serve many clinics. For example, if a patient has a rash that is difficult to diagnose, the primary care doctor will take a picture and send it to the dermatologist for assistance.

For services beyond primary care and basic specialty consultation, insurance will still apply. The premiums for these policies will be much lower because primary care will be excluded from coverage.

How to get “there” from “here”

Think Starbucks – after the development of the prototype design based on currently successful models, with proper funding, centers can be built quickly. Attracting primary care providers, dentists, and mental health care providers will be key to success.

Basic services can be instituted first – immunizations, preventive care, reproductive care, and chronic disease management programs can be standardized and easily delivered by ancillary care providers and community health workers. Epidemic and bioterrorist management modules can be provided to each center. As the primary care workforce is rebuilt, further services can be added such as acute care visits, basic specialty consultations, and expanded dental and mental health care.

With the implementation of this primary care system, payment reform can be addressed. Less expensive policies can immediately be offered that exclude primary care. Ideally, we will move toward a value-based payment system for specialty care. The decision on Medicare for all, a totally private payer system, or a public and private option can be made. Thankfully, during the political discourse, 75% of the population will have their needs fully met and our country will start down the road to better health.

Well, this Fox & Friends Twitter poll on “Medicare for All” didn’t go as planned

Christopher Zara reported that in today’s edition of “Ask and Ye Shall Receive,” here’s more evidence that support for universal health care isn’t going away.

The Twitter account for Fox & Friends this week ran a poll in which it asked people if the benefits of Bernie Sanders’s “Medicare for All” plan would outweigh the costs. The poll cites an estimated cost of $32.6 trillion. Hilariously, 73% of respondents said yes, it’s still worth it—which is not exactly the answer you’d expect from fans of the Trump-friendly talk show.

Granted, this is just a Twitter poll, which means it’s not scientific and was almost certainly skewed by retweets from Twitter users looking to achieve this result.

At the same time, it’s not that far off from actual polling around the issue. In March, a Kaiser Health tracking poll revealed that 6 in 10 Americans are in favor of a national healthcare system in which all Americans would get health insurance from a single government plan. Other polls have put the number at less than 50% support but trending upward.

If you’re still unsure, you can read more about Sanders’s plan and stay tuned for more discussion on “Medicare for All”.

Should we all be even concerned about any of these health care problems if AOC is right and the world ends in 12 years? Good young Ocasio Cortez, if she only had ahold on reality!! Her ideas will cost us all trillions of dollars, tax dollars, which we will all pay! Are we all ready for the Green Revolution?

 

 

 

 

House Panel Mulls ACA Fixes, Responses to Trump Policies and Healthcare is a Big Player in State of the Union Speech

50872986_1884394221690228_3042478004111409152_nPresident Trump proposes plans to end AIDS, fight childhood cancer.

Actually, I thought that President Trump did a good job even being conciliatory in his State of the Union speech even covering various aspects of healthcare. Joyce Frieden the News Editor of MedPage stated that Healthcare played a major part in Tuesday’s State of the Union address, with President Trump covering a wide variety of health-related topics.

Only a few minutes into the speech, the president foreshadowed some of his healthcare themes. “Many of us have campaigned the same core promises to defend American jobs and … to reduce the price of healthcare and prescription drugs,” Trump said. “It’s a new opportunity in American politics if only we have the courage together to seize it.”

A few minutes later, he touted some of his administration’s actions so far. “We eliminated the very unpopular Obamacare individual mandate penalty,” Trump said. “And to give critically ill patients access to lifesaving cures, we passed — very importantly — the right to try.”

Drug Prices a Major Player

The subject of drug prices occupied a fair amount of time. “The next major priority for me, and for all of us, is to lower the cost of healthcare and prescription drugs and to protect patients with preexisting conditions,” he said. “Already, as a result of my administration’s efforts in 2018, drug prices experienced their single largest decline in 46 years. But we must do more. It’s unacceptable that Americans pay vastly more than people in other countries for the exact same drugs, often made in the exact same place.”

“This is wrong; this is unfair, and together we will stop it, and we’ll stop it fast,” he said. “I am asking the Congress to pass legislation that finally takes on the problem of global freeloading and delivers fairness and price transparency for American patients, finally.”

He then turned to several other health topics. “We should also require drug companies, insurance companies, and hospitals to disclose real prices, to foster competition, and bring costs way down,” Trump said. He quickly moved on to the AIDS epidemic. “In recent years we’ve made remarkable progress in the fight against HIV and AIDS. Scientific breakthroughs have brought a once distant dream within reach. My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years.”

“We have made incredible strides, incredible,” he added to applause from members of Congress on both sides of the aisle. “Together we will defeat AIDS in America and beyond.”

Childhood Cancer Initiative

Although the remarks on HIV had been expected, the president also announced another health initiative that wasn’t as well-known: a fight against childhood cancer. “Tonight I’m also asking you to join me in another fight all Americans can get behind — the fight against childhood cancer,” he said, pointing out a guest of First Lady Melania Trump: Grace Eline, a 10-year-old girl with brain cancer.

“Every birthday, since she was 4, Grace asked her friends to donate to St. Jude’s Children’s Hospital,” Trump said. “She did not know that one day she might be a patient herself [but] that’s what happened. Last year Grace was diagnosed with brain cancer. Immediately she began radiation treatment, and at the same time she rallied her community and raised more than $40,000 for the fight against cancer.”

“Many childhood cancers have not seen new therapies in decades,” he said. “My budget will ask Congress for $500 million over the next 10 years to fund this critical life-saving research.”

These health initiatives met with mixed reactions. “President Trump is taking a bold step to design an innovative program and strategy, and commit new resources, to end HIV in the United States … Under the President’s proposal, the number of new infections can eventually be reduced to zero,” Carl Schmid, deputy executive director of The AIDS Institute, said in a statement. Michael Ruppal, the institute’s executive director, added, “While we might have policy differences with the president and his administration, this initiative if properly implemented and resourced, can go down in history as one of the most significant achievements of his presidency.”

But the Democratic National Committee (DNC) wasn’t quite so enthusiastic; it sent an email calling the goal of ending HIV by 2030 “notable” but added, “The Trump administration has consistently undermined advancements in HIV/AIDS research, attacked people living with HIV/AIDS, and sabotaged access to quality healthcare at every opportunity.” Among other things, the administration redirected money from the Ryan White HIV/AIDS Program to help fund the separation of immigrant families, and proposed cutting global HIV/AIDS funding by over $1 billion, which could cause 300,000 deaths per year, the DNC said.

Abortion in the Spotlight

As for the childhood cancer initiative, “$500 million over 10 years to solve childhood cancer is … not a lot,” one Bloomberg reporter tweeted. However, Gail Wilensky, Ph.D., a senior fellow at Project HOPE, in Bethesda, Maryland, pointed out that this amount ” is in addition to the National Institutes of Health budget [for cancer] … A lot of money is going to cancer anyway [already] and the National Cancer Institute been one of the more protected parts of government, so it’s not like they have a big deficit to make up.”

Overall, “it was a surprisingly good speech,” said Wilensky, who was the administrator of the Centers for Medicare & Medicaid Services under President George H.W. Bush. “It covered a lot of areas, and there were a number of issues that were very hard not to applaud … I thought he did a pretty admirable job of forcing applause and a sense of togetherness by the country, talking about compromise and the common good.”

The president also touched on a more controversial area of healthcare: abortion. He referred to a recent abortion bill that passed in New York State and another that failed in Virginia — both of which dealt with abortion late in pregnancy — adding, “I’m asking Congress to pass legislation to prohibit late-term abortion of children who can feel pain in a mother’s womb. Let us work together to build a culture that cherishes innocent life.”

That appeal to the anti-abortion movement “is a position that Republicans have taken in the past, which is the importance of life right after birth and life right before birth,” said Wilensky. Abortion later in pregnancy “is an area that tends to engender a more unified response than most others, even for people who are ambivalent or more supportive of abortion rights. Very late-term abortion makes people uncomfortable … It’s easy to understand why people get uneasy.”

“Already, the biggest move the Trump administration has made to control health care costs and access has been on the regulatory front,” said Bob Laszewski, founder of Health Policy and Strategy Associates, an Alexandria, Virginia, consulting firm, citing the announcement of proposed regulations to end drug rebates under Medicare and Medicaid kickback rules and rules for short-term health plans. “I take it from Trump’s remarks that they will continue with this regulatory approach instead of waiting for any bipartisanship in the Congress,” he said.

“The only area there now seems to be a hint of bipartisanship is over the issue of drug prices being too high,” Laszewski added. “It was clear from Trump’s remarks, and the Democrats’ positive response on this one issue, that this could become an area for cooperation.”

No Large-Scale Reforms Offered

Rosemarie Day, a healthcare consultant in Somerville, Massachusetts, said in an email that the president “certainly did not propose any large-scale reforms to the healthcare system during the speech, and he was short on specifics for most of it. According to a recent Kaiser Family Foundation poll, health care is the number one issue among voters so this may appear to some as a missed opportunity. It’s increasingly looking like Republicans are leaving the big health care reform ideas to the Democratic presidential candidates.”

The ideas he did propose “were mostly noncontroversial and somewhat vague,” Day continued. “The more interesting proposal was lowering the cost of healthcare and drugs, which is a high priority for consumers. The way he discussed going about it was by requiring drug companies, insurance companies, and hospitals to disclose real prices. This raises many questions, such as what does a ‘real’ price mean? … This will be an interesting area to watch, since ‘real prices’ are currently closely held secrets, and a legal requirement to disclose them would constitute a significant change from the status quo.”

In the Democratic response to the speech, Stacey Abrams, a Democrat who ran unsuccessfully last year for governor of Georgia, lashed out against enemies of Obamacare. “Rather than suing to dismantle the Affordable Care Act as Republican attorneys general have, our leaders must protect the progress we’ve made and commit to expanding healthcare and lowering costs for everyone,” said Abrams, the first black woman to deliver the rebuttal to a State of the Union address.

She also spoke of her personal struggle with healthcare costs for her family. “My father has battled prostate cancer for years. To help cover the costs, I found myself sinking deeper into debt because, while you can defer some payments, you can’t defer cancer treatment. In this great nation, Americans are skipping blood pressure pills, forced to choose between buying medicine and paying rent.”

She also pushed back against state governors and legislators who continue their resistance to Medicaid expansion. “In 14 states, including my home state, where a majority want it, our leaders refused to expand Medicaid which could save rural hospitals, save economies and save lives.”

With Dems now in charge, repeal-and-replace no longer on the table!

Former Rep. John Dingell Left An Enduring Health Care Legacy

If anyone is interested in healthcare and its history here in the U.S. one must include the legacy of former Rep. John Dingell, the Michigan Democrat who holds the record as the longest-serving member of the U.S. House, died Thursday night in Michigan. Julie Rovner reviewed his history last week after his death. He was 92.

And while his name was not familiar to many, his impact on the nation, and on health care, in particular, was immense.

For more than 16 years Dingell led the powerful House Energy and Commerce Committee, which is responsible for overseeing the Medicare and Medicaid programs, the U.S. Public Health Service, the Food and Drug Administration and the National Institutes of Health.

Dingell served in the House for nearly 60 years. As a young legislator, he presided over the House during the vote to approve Medicare in 1965.

As a tribute to his father, who served before him and who introduced the first congressional legislation to establish national health insurance during the New Deal, Dingell introduced his own national health insurance bill at the start of every Congress.

And when the House passed what would become the Affordable Care Act in 2009, leaders named the legislation after him. Dingell sat by the side of President Barack Obama when he signed the bill into law in 2010.

Dingell was “a beloved pillar of the Congress and one of the greatest legislators in American history,” said a statement from House Speaker Nancy Pelosi. “Yet, among the vast array of historic legislative achievements, few hold greater meaning than his tireless commitment to the health of the American people.”

He was not always nice. Dingell had a quick temper and a ferocious demeanor when he was displeased, which was often. Witnesses who testified before him could feel his wrath, as could Republican opponents and even other committee Democrats. And he was fiercely protective of his committee’s territory.

In 1993, during the effort by President Bill Clinton to pass major health reform, as the heads of the three main committees that oversee health issues argued over which would lead the effort, Dingell famously proclaimed of his panel, “We have health.”

Dingell and his health subcommittee chairman, California Democrat Henry Waxman, fought endlessly over energy and environmental issues. Waxman, who represented an area that included western Los Angeles, was one of the House’s most active environmentalists. Dingell represented the powerful auto industry in southeastern Michigan and opposed many efforts to require safety equipment and fuel and emission standards.

In 2008, Waxman ousted Dingell from the chairmanship of the full committee.

But the two were of the same mind on most health issues, and together during the 1980s and early 1990s they expanded the Medicaid program, reshaped Medicare and modernized the FDA, NIH and the Centers for Disease Control and Prevention.

“It was always a relief for me to know that when he and I met with the Senate in the conference, we were talking from the same page, believed in the same things, and we were going to fight together,” Waxman said in 2009.

Dingell was succeeded in his seat by his wife, Rep. Debbie Dingell, herself a former auto industry lobbyist.

House Panel Mulls ACA Fixes, Responses to Trump Policies

Now to the article of the week, Ryan Basen, a writer for MedPage noted that focusing on preventive care, expanding subsidies, and regulating association health plans (AHPs) were among the solutions proposed Tuesday to aid Americans with pre-existing health conditions, as the U.S. House Ways and Means Committee held its first hearing under the new Congress.

While the hearing was entitled “Protecting Americans with Pre-Existing Conditions,” much discussion centered around the policies within the Affordable Care Act, Republican efforts to repeal it, and recent reforms that tweaked American healthcare. Many lawmakers used their allotted time to blast other party members for either being too supportive of the ACA or attempting to “sabotage” it. Some lawmakers, however, promised to work together with members of the opposing party to help patients with pre-existing conditions — which some noted includes themselves and family members.

“Protections for people with pre-existing conditions has become the defining feature of the Affordable Care Act,” said witness Karen Pollitz, a senior fellow with the Kaiser Family Foundation; she noted that these protections also enjoy widespread public support.

The ACA forced insurance plans to accept and retain members with pre-existing conditions, many of whom could not afford plans before the legislation was enacted. But Trump administration policies and other reforms worry some experts and lawmakers that the millions of American with pre-existing conditions — ranging from moderate mental health diagnoses to cancer — are gradually being priced out of the healthcare system again, they said.

Protecting patients with pre-existing conditions are linked to controlling costs throughout American healthcare, many said. Recent legislation led to “artificial” cost increases for ACA marketplace plans and pushed some insurers to leave the market altogether, Pollitz said. These policies also have driven up premium prices.

“What we have here is an infrastructure problem,” Rep. John Larson (D-Conn.) said. “The disagreements are over how to pay for it.”

“All we are really debating here is who gets to pay,” Rep. David Schweikert (R-Ariz.) said. “It’s time for radical rethinking: Are you [Democrats] willing to work with us to break down the barriers to having cost disruption?”

Several who spoke Tuesday offered potential solutions. Witness Keysha Brooks-Coley, of the American Cancer Society Cancer Action Network, suggested lawmakers strengthen the ACA by addressing its so-called “family glitch” and eliminating the “subsidy cliff”; both policies currently withhold subsidies from many Americans who need them to pay for healthcare, she said.

Rep. Brad Wenstrup, DPM (R-Ohio), called for turning lawmakers’ focus from squabbling about politics to studying preventative care. “There’s no part of me as a doctor that doesn’t want Americans to have access to quality healthcare,” the podiatrist said. “But I don’t necessarily agree with the direction (the ACA) went.”

“Let’s talk about incentivizing health: What do we have not only for the patient but for the physician?” he added. “Think about who gets rewarded in today’s system. Do we recognize the doctor who prevented the patient from needing open-heart surgery? That’s where we need to go if you want to talk about the cost curve.”

One solution is actually quite simple, according to witness Rob Roberston, secretary-treasurer for the Nebraska Farm Bureau: regulate AHPs and encourage individuals to band together in groups to reduce premium costs, as many farmers and ranchers have in Nebraska. “This is not a political issue,” he said. “This is an issue of hardship, and we need to fix these individual markets and protect pre-existing conditions at the same time.”

Alas, judging by many lawmakers’ tone during a hearing that stretched over four hours, this does appear to be a political issue. “It’s really this long debate over Obamacare,” Rep. Devin Nunes (R-Calif.) said. “We really need to work for a solution because Obamacare wasn’t a solution.”

Rep. Lloyd Doggett (D-Texas) then got into it. “What has led us here has been eight years of Republican persistence in trying to destroy the Affordable Care Act,” he said. “It’s great to hear they [Republicans] want to work with us and I hope they do.” The ACA is not perfect, Doggett acknowledged, but he quipped that perhaps “the most pre-existing condition” present Tuesday was “the political amnesia of those who have forgotten what it was like before the Affordable Care Act.”

Raising his voice, Rep. Earl Blumenauer (D-Ore.) echoed the point: “If we would have been working together for the last six years to refine the Affordable Care Act, costs would be lower, coverage would be better.”

Many witnesses spoke against the Administration’s policy to loosen regulations on cheaper short-term plans that do not have to abide by ACA strictures. “The expansion of these plans does not help the consumer,” Brooks-Coley said. “It puts them at increased risk. … They are only less expensive upfront because they don’t cover [serious conditions].” In addition, Pollitz noted, many of these plans drop patients once they become ill and “have been shown to increase costs of ACA-compliant plans.”

The witnesses were asked to gauge what would happen if protections for patients with pre-existing conditions were to be removed. Younger women would pay more than men the same age, Pollitz said, and all pre-existing patients “would find it much more difficult to find coverage.”

“True harm would come,” Andrew Stolfi, Oregon Division of Financial Regulation’s insurance commissioner, told the committee. He cited Oregon’s pre-ACA experience: “You were lucky if you were even given the choice to take an insurer’s limited terms.”

Ways and Means chairman Richard Neal (D-Mass.) ended the hearing with optimism: “Today I heard a lot of members on the other side of the aisle say they support [requiring coverage for] pre-existing conditions, and I welcome that and hope we can work together.”

So, now what do the physicians think is needed to improve our health care system? Next week let’s discuss.

Kamala Harris Vows to ‘Eliminate’ Private Insurance Market and Medicare For All

 

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The children in Washington are still fighting over the wall but, my wife found out why I’m not a fan of Medicare-For-All this past weekend. She finally found out how expensive it is for our family, which is just the two of us. She added up the fees, including secondary insurance, etc. and it came up with a yearly cost of $13,000. So, there is nothing free here. And if the government pays these costs to imagine the cost and who is going to pay for this program?

Jack Crowe from the National Review reported that Senator Kamala Harris (D., Calif.) advocated the elimination of the private health insurance industry during a CNN town hall event in Iowa Monday night.

Harris, who announced her 2020 presidential candidacy this week, broke from previous Democratic healthcare orthodoxy, which held that Americans could retain their private insurance if they so chose, in favor of a single-payer plan in which the government is the sole health insurance provider.

“I believe the solution — and I actually feel very strongly about this — is that we need to have Medicare for all,” Harris said in response to an audience question about healthcare affordability. “That’s just the bottom line.”

“So for people out there who like their insurance, they don’t get to keep it?” CNN’s Jake Tapper asked.

“Let’s eliminate all of that,” Harris responded, “let’s move on.”

Harris went on to describe the current healthcare system as “inhumane” and argued that switching over to a single payer system would reduce the financial and bureaucratic barriers to quality health care.

“Well, listen, the idea is that everyone gets access to medical care, and you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require,” she said. “Who of us has not had that situation where you’ve got to wait for approval, and the doctor says, well, I don’t know if your insurance company is going to cover this. Let’s eliminate all of that. Let’s move on.”

Employing the language of human rights, the Democratic establishment has increasingly embraced “Medicare For All” in recent years as young, healthy Americans — previously burdened by the threat of a punitive tax on the uninsured, which the Trump administration recently eliminated — have increasingly fled government exchanges, exposing older, sick consumers to even steeper premiums.

The policy, which is widely viewed as a litmus test among potential Democratic presidential candidates, mandates that every American purchase their health insurance through the government. It would require $32.6 trillion in new spending over ten years, according to the Mercatus Center. Doubling the corporate and individual income tax would not cover the cost of the program, according to the analysis.

Kamala Harris Backtracks After Vowing to ‘Eliminate’ Private Insurance Market

Jack Crowe then followed up on this announcement by Harris noting that after advocating the elimination of the private insurance market during CNN’s town hall in Iowa Monday night, Senator Kamala Harris (D., Calif.) appeared to backtrack on Tuesday amid criticism from moderate Democrats and Republicans alike.

Remember her announcement “Let’s eliminate all of that,” Harris said when asked by CNN’s Jake Tapper if, under her proposed “Medicare For All” proposal, Americans with private insurance plans could retain them.

“Let’s move on,” she added.

The remarks immediately drew condemnation from former Starbucks CEO Howard Schultz, who recently launched an independent bid for president, and Mike Bloomberg, the centrist former mayor of New York City.

In response, Harris’s national press secretary Ian Sams and an unnamed advisor told CNN that she would also be open to pursuing more moderate healthcare reforms that would allow the 177 million Americans currently using private health insurance plans to keep them.

“Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period,” Sams told CNN. “She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.”

During her time in the Senate, Harris has co-sponsored Senator Bernie Sanders (D., Vt.) “Medicare For All” bill, which would entirely phase out the private insurance industry, but has also proven willing to embrace the more moderate “public option,” which would allow more Americans to buy into Medicaid while leaving the private market largely intact.

Kamala Harris and the Implausibility of ‘Medicare-for-All’

Then Rich Lowry noted that Senator Kamala Harris committed a most unusual gaffe at her CNN town hall the other night — not by misspeaking about one of her central policy proposals, but by describing it accurately.

Asked on Monday night if the “Medicare-for-all” plan that she’s co-sponsoring with Senator Bernie Sanders eliminates private health insurance, she said that it most certainly does. Citing insurance company paperwork and delays, she waved her hand: “Let’s eliminate all of that. Let’s move on.”

She met with approbation from the friendly audience in Des Moines, Iowa, but the reaction elsewhere was swift and negative.

“As the furor grew,” CNN reported the next day, “a Harris adviser on Tuesday signaled that the candidate would also be open to the more moderate health reform plans, which would preserve the industry, being floated by other congressional Democrats.”

This was a leading Democrat wobbling on one of her top priorities 48 hours after the kickoff of her presidential campaign, which has been praised for its early acumen. It is sure to be the first of many unpleasant encounters between the new Democratic agenda and political reality.

Democrats are now moving from the hothouse phase of jockeying for the nomination, when all they had to do was get on board the party’s orthodoxy as defined by Bernie Sanders, to defending these ideas in the context of possibly signing them into law as president of the United States.

The Harris flap shows that insufficient thought has been given to how these proposals will strike people not already favorably disposed to the new socialism. It’s one thing for Sanders to favor eliminating private health insurance; no one has ever believed that he is likely to become president. It’s another for Harris, deemed a possible front-runner, to say it.

Her position is jaw-droppingly radical. It flips the script of the (dishonest) Barack Obama pledge so essential to passing Obamacare: “If you like your health-care plan, you’ll be able to keep your health-care plan, period. No one will take it away, no matter what.”

That was a very 2009 sentiment. Ten years later, Harris indeed wants to take away your health plan, not in a stealthy operation, not as an unfortunate byproduct of the rest of her plan, but as a defining plank of her agenda.

This is a far more disruptive idea than Senator Elizabeth Warren’s wealth tax. The affected population isn’t a limited group of highly affluent people. It is half the population, roughly 180 million people who aren’t eager for the government to swoop in and nullify their current health-care arrangements.

They may not like the current system, but they like their own health care — about three-quarters tell Gallup that their own health care is excellent or good. This is why the relatively minor interruption of private plans as part of the rollout of Obamacare was so radioactive.

How is a President Harris going to overcome this kind of resistance absent Depression-era Democratic supermajorities in Congress? Not to mention pay for a program that might well cost $30 trillion over 10 years and beat back fierce opposition from key players in the health-care industry?

She obviously won’t. “Medicare-for-all” is a wish and a talking point rather than a realistic policy. When her aides say she is willing to accept another “path” to “Medicare-for-all,” what they mean is that Harris is willing to accept something short of true “Medicare-for-all.”

There is always something to be said for shifting the Overton window on policy. But it’s better if think tanks and gadflies rather than plausible presidential candidates who aren’t even trying to hold down the left flank of the party do that.

If it’s uncomfortable for Kamala Harris to defend eliminating private health insurance now, imagine what it will be like when the entire apparatus of the Republican Party — including the president’s Twitter feed — is aimed at her in a general election.

What do Californians think about Kamala Harris’ far-left agenda?

Campus Reform editor-in-chief Lawrence Jones hit the streets of Los Angeles to see how people view the 2020 Democratic presidential candidate’s progressive proposals.

People expressed enthusiasm for Harris’ agenda, which includes Medicare-for-all, free college and rolling back President Trump’s tax plan.

When asked how they would pay for healthcare and college for every American, people responded with “Figure it out!” and “It’s in someone’s pockets, so why not share?”

On “Fox & Friends” Thursday, Jones said he spoke to many people who acknowledged that Harris’ agenda is not affordable or practical, but they like her and what she’s saying.

“This just shows you where this emotion-driven, progressive policy has taken this country,” Jones said.

He said Campus Reform has explored that troubling trend on college campuses, and now he’s increasingly seeing it among adults.

“That’s why people should be concerned because Obama won because he connected with voters,” Jones said. “Let’s see what happens now.”

‘Medicare-for-all’ means long waits for poor care, and Americans won’t go for it once they learn these facts

Progressive Democrats push ‘Medicare-for-all’ platform.

Critics say to provide ‘Medicare-for-all,’ taxes would have to go up while quality, choice, and access to care would go down; chief congressional correspondent Mike Emanuel reports.

Sally Pipes of Fox News pointed out that this week, as I have already stated, Sen. Kamala Harris, D-Calif., one of the front-runners in the race for the Democratic Party’s presidential nomination, revealed her radical vision for American health care – outlawing private health insurance and putting the government in charge of the system.

Harris, along with 15 of her Democratic colleagues, supports Sen. Bernie Sanders’, I-Vt., the vision of “Medicare-for-all.” Sanders’ 2017 bill, S.1804, was explicit about outlawing private health insurance. At a town hall in Iowa last Again, remember Monday when Harris confirmed she was on board with that idea. “Let’s eliminate all of that,” she said.

In other words, Harris is running for president on a platform of taking away the private insurance coverage of about 200 million people and dumping everyone into a one-size-fits-all government-run health plan that would cost taxpayers trillions of dollars. And if the experiences of other countries with single-payer health care are any indication, it would result in long waits for poor care.

I’M A NOT A DEMOCRAT, ACTUALLY AN INDEPENDENT, BUT MEDICARE FOR ALL IS NOT THE ANSWER — HERE ARE FOUR SUGGESTIONS

Support for single-payer appears to be the price of admission to the Democratic presidential race. Harris’s fellow presidential aspirants, Sens. Elizabeth Warren, D-Mass., Kirsten Gillibrand, D-N.Y., and Cory Booker, D.-N.J., were among the co-sponsors of Sanders’ 2017 “Medicare-for-all” legislation. And it’s only a matter of time before Sanders himself, the pied piper of the “Medicare-for-all” movement, joins the race.

“Medicare-for-all’s” advocates promise a health care system that’s free at the point of service – no co-pays, no deductibles, no coinsurance.

They tend to be less upfront about how they’d pay for it. Independent estimates from both the right and the left peg “Medicare-for-all’s” cost at about $32 trillion over 10 years. Doubling what the federal government takes in individual and corporate income tax revenue wouldn’t be enough to cover that tab.

That’s assuming “Medicare-for-all” is able to implement its financing strategy. The bill proposes reimbursing doctors and hospitals at Medicare’s current rates, which are 40 percent below what private insurance pays.

Health care providers are unlikely to just absorb those cuts. Those with narrow margins – say, in rural areas – may be forced to close, unable to cover their costs. Some doctors may respond to lower payments by seeing fewer patients, retiring early, or leaving the practice of medicine altogether. Bright young people may decide not to pursue careers in medicine, given that “Medicare for all” will limit their earning power.

Regardless, ratcheting down the price of care by force is going to cause health care providers to supply less of it. And that will lead to longer waits for patients.

American patients will not stand for the higher taxes and lower-quality care that “Medicare-for-all” would bring.

Long waits plague patients in other countries with government-run health care. Take Canada, which outlaws private health insurance for anything considered medically necessary, just as “Medicare for all” would. The median wait for treatment from a specialist following referral by a general practitioner is 19.8 weeks, according to the Fraser Institute, a Vancouver-based think tank. In 1993, the median wait was less than half as much – 9.3 weeks.

Waits are far longer for some specialties. For orthopedic surgery, the median wait for specialist treatment is 39 weeks.

Many Canadians are uninterested in waiting multiple months for treatment, particularly if they’re in pain or fear they may have a serious illness. So they pay out of pocket for care abroad. In 2016, more than 63,000 Canadians went to another country to receive medical treatment.

On the other side of the Atlantic, the United Kingdom’s government-run, 70-year old National Health Service, is proving similarly incapable of providing quality care. The system is currently short 100,000 health professionals – doctors, nurses, and other workers.

It’s no wonder 14 percent of operations are canceled right before they are supposed to happen, usually due to a shortage of staff or beds. Last July, 4.3 million patients were waiting for an operation – the highest figure in a decade.

During the winter, the system goes into crisis mode. Between December 2017 and February 2018, more than 163,000 patients waited in corridors and ambulances for over 30 minutes before being admitted to the emergency room. To deal with the crunch, officials ordered hospitals to cancel 50,000 operations.

American patients will not stand for the higher taxes and lower-quality care that “Medicare-for-all” would bring. A majority of people, 55 percent, erroneously believes that they’d be able to keep their private insurance under such a system. Once they learn it would eliminate private health insurance, support for the idea plummets, from 56 percent to 37 percent. The same happens after they learn it would require higher taxes.

Seven in 10 Americans say they’d oppose “Medicare-for-all” if it led to delays in getting some treatments and tests. Such delays are not hypothetical – they’re endemic to single-payer.

Harris and her fellow Democrats may think “Medicare-for-all” is their ticket to the White House. But voters are not interested in their plan to eliminate private health insurance.

And now, this past week, one of the potential Presidential candidates Senator Kirsten Gillibrand a backer of Medicare-For-All, announced that she thought that Medicaid-For-All made sense also. Really, do you all know what Medicaid pays the physicians???? 10 cents on the dollar, which is why my practice doesn’t accept any Medicaid patients. But maybe for primary care using nurse practitioners and physician assistants, this might work as basic care for “All”.

More to discuss.

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Trump Seeks Action To Stop Surprise Medical Bills

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Pew Charitable Trusts

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

Now, voters will decide for themselves.

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

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

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

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

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

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

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

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

Extending Benefits to Childless Adults

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘That Is Socialism’

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

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

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

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

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

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

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

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

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

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

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

Their beliefs about expansion don’t fly with him.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The burden of Uncompensated Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New Maine governor orders Medicaid expansion

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

‘Medicare for all’ advocates emboldened by ObamaCare lawsuit

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Calif. Medical Assn. President Shares Medical Horror Story

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

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

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

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

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

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

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

The likely first item on the Democratic agenda: Obamacare stabilization

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

She said she hopes she can change that.

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

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

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

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

 

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

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

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

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

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

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

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

Opioid ‘Ground Zero’

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

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

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

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

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

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

An Unlikely Winner

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

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

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

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

Post-Election Plans

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

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

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

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

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

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

Questioning the 80/20 rule for healthcare

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Healthcare and the midterms: I’ve got you covered

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

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

Midterm elections 2018 at a glance

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

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

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

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

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

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

Status of Medicaid expansion states and work requirements

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

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

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

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

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

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

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

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

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

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

Healthcare reform issues

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

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

Affordable Care Act:

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

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

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

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

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

Pre-existing conditions:

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

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

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

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

Medicare for all:

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

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

Drug prices in America

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

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

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

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

Midterms 2018 ballot measures

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

Nurse-to-patient staffing ratios in Massachusetts

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

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

Dialysis ballot measure in California:

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

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

Impact of immigration on healthcare

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

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

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

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

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

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

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

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