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Rural healthcare a Top Issue Among Voters for 2020 and Such Bad Patients Here in the U.S. More Important-Happy Father’s Day!!

Annotation 2019-06-15 220837Voters want 2020 candidates to start talking about access to healthcare in rural America — in fact, most say it would swing their vote, according to a poll conducted by survey research firm Morning Consult and the Bipartisan Policy Center.

The poll hit on a rare area of bipartisan agreement in the healthcare debate: 93 percent of Republicans and 92 percent of Democrats said making it easier to access healthcare in rural communities is important to them. The issue was also consistent across rural and nonrural voters: 91 percent of nonrural voters and 95 percent of rural voters said this was an important issue.

Three in 5 voters said they would be more likely to vote for a candidate who includes expanding rural healthcare access as part of their platform.

Unsurprisingly, rural voters said they had less access to healthcare in all its forms: primary care physicians, hospitals, specialists, pharmacies and urgent care.

The poll is based on survey responses from 1,995 voters across the country, in addition to 200 rural voters from Iowa, 200 rural voters from North Carolina and 200 rural voters from Texas. It was conducted in May.

Who are the Worst Patients in the World?

Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need and fail to take the ones we do. No wonder the U.S. leads the world in health spending.

David H. Freedman noted that he was standing two feet away when his 74-year-old father slugged an emergency-room doctor who was trying to get a blood-pressure cuff around his arm. I wasn’t totally surprised: An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health. He typically limited himself to berating or rolling his eyes at the unlucky clinicians tasked with ministering to him, but more than once I could tell he was itching to escalate.

My father was what the medical literature traditionally labeled a “hateful patient,” a term since softened to “difficult patient.” Such patients are a small minority, but they consume a grossly disproportionate share of clinician attention. Nevertheless, most doctors and nurses learn to put up with them. The doctor my dad struck later apologized to me for not having shown more sensitivity in his cuff placement.

When he wasn’t in the hospital, my dad blew off checkups and ignored signs of sickness, only to reenter the health-care system via the emergency department. Once home again, he enthusiastically undermined whatever his doctors had tried to do for him, practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.

It was in his self-neglect, rather than his hostility, that my father found common cause with the tens of millions of American patients who collectively hobble our health-care system.

For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?

One hint that patient behavior matters a lot is the tremendous variation in health outcomes among American states and even counties, despite the fact that they are all part of the same health-care system. A 2017 study published in JAMA Internal Medicine reported that 74 percent of the variation in life expectancy across counties is explained by health-related lifestyle factors such as inactivity and smoking, and by conditions associated with them, such as obesity and diabetes—which is to say, by patients themselves. If this is true across counties, it should be true across countries too. And indeed, many experts estimate that what providers do accounts for only 10 to 25 percent of life-expectancy improvements in a given country. What patients do seems to matter much more.

Somava Saha, a Boston-area physician who for more than 15 years practiced primary-care medicine and is now a vice president at the nonprofit Institute for Healthcare Improvement, told me that several unhealthy behaviors common among Americans (for example, a sedentary lifestyle) are partly rooted in cultural norms. Having worked on health-care projects around the world, she has concluded that a key motivator for healthy behavior is feeling integrated into a community where that behavior is commonplace. And sure enough, healthy community norms are particularly evident in certain places with strong outcome-to-cost ratios, like Sweden. Americans, with our relatively weak sense of community, are harder to influence. “We tend to see health as something that policymaking or health-care systems ought to do for us,” she explained. To address the problem, Saha fostered health-boosting relationships within patient communities. She notes that patients in groups like these have been shown to have significantly better outcomes for an array of conditions, including diabetes and depression than similar patients not in groups.

The absence of healthy community norms goes a long way toward explaining poor health outcomes, but it doesn’t fully account for the extent of American spending. To understand that, we must consider Americans’ fairly unusual belief that, when it comes to medical care, money is no object. A recent survey of 10,000 patients found that only 31 percent consider cost very important when making a health-care decision—versus 85 percent who feel this way about a doctor’s “compassion.” That’s one big reason the push for “value-based care,” which rewards providers who keep costs down while achieving good outcomes, is not going well: Attempts to cut back on expensive treatments are met with patient indignation.

For example, one cost-reduction measure used around the world is to exclude an expensive treatment from health coverage if it hasn’t been solidly proved effective, or is only slightly more effective than cheaper alternatives. But when American insurance companies try this approach, they invariably run into a buzz saw of public outrage. “Any patient here would object to not getting the best possible treatment, even if the benefit is measured not in extra years of life but in months,” says Gilberto Lopes, the associate director for global oncology at the University of Miami’s cancer center. Lopes has also practiced in Singapore, where his very first patient shocked him by refusing the moderately expensive but effective treatment he prescribed for her cancer—a choice that turns out to be common among patients in Singapore, who like to pass the money in their government-mandated health-care savings accounts on to their children.

Most experts agree that American patients are frequently overtreated, especially with regard to expensive tests that aren’t strictly needed. The standard explanation for this is that doctors and hospitals promote these tests to keep their income high. This notion likely contains some truth. But another big factor is the patient preference. A study out of Johns Hopkins’s medical school found doctors’ two most common explanations for overtreatment to be patient demand and fear of malpractice suits—another particularly American concern.

In countless situations, such as blood tests that are mildly out of the normal range, the standard of care is “watchful waiting.” But compared with patients elsewhere, American patients are more likely to push their doctors to treat rather than watch and wait. A study published in the Journal of the American Board of Family Medicine suggested that American men with low-risk prostate cancer—the sort that usually doesn’t cause much trouble if left alone—tend to push for treatments that may have serious side effects while failing to improve outcomes. In most other countries, leaving such cancers alone is not the exception but the rule.

American patients similarly don’t like to be told that unexplained symptoms aren’t ominous enough to merit tests. Robert Joseph, a longtime ob‑gyn at three Boston-area hospital systems who last year became a medical director at a firm that runs clinical trials, says some of his patients used to come in demanding laparoscopic surgery to investigate abdominal pain that would almost certainly have gone away on its own. “I told them about the risks of the surgery, but I couldn’t talk them out of it, and if I refused, my liability was huge,” he says. Hospitals might question non-indicated and expensive surgeries, he adds, but saying the patient insisted is sometimes enough to close the case. Joseph, like many American doctors, also worried about getting a bad review from a patient who didn’t want to hear “no.” Such frustrations were a big reason he stopped practicing, he says.

In most of the world, what the doctor says still goes. “Doctors are more deified in other countries; patients follow orders,” says Josef Woodman, the CEO of Patients Beyond Borders, a consulting firm that researches international health care. He contrasts this with the attitude of his grown children in the U.S.: “They don’t trust doctors as far as they can throw them.” (For what it’s worth, patients in China may be even worse than American patients in this regard. According to one report, they spend an average of eight hours a week finding and sharing information online about their medical conditions and health-care experiences. Various observers have told me that Chinese patients wield that information like a club, bullying doctors into providing as many prescriptions as possible.)

American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.

Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”

It makes sense that a wealthy nation with unhealthy lifestyles, little interest in preventive medicine, and expectations of limitless, top-notch specialist care would empower its health-care system to accommodate these preferences. It also makes sense that a health-care system that has thrived by throwing over-the-top care at patients has little incentive to push those same patients to embrace care that’s less flashy but may do more good. Medicare for All could provide that incentive by refusing to pay for unnecessarily expensive care, as Medicare does now—but can it prepare patients to start hearing “no” from their physicians?

Marveling at what other systems around the world do differently, without considering who they’re doing it for, is madness. The American health-care system has problems, yes, but those problems don’t merely harm Americans—they are caused by Americans. And more importantly, what do we do about it to contribute to improving our health care system?? Any suggestions??

More on the History of Medicare and Other Healthcare Reforms

Remember last week’s conversation as we realized that with the assignation of President Kennedy that Congressional support swelled. President Lyndon Johnson pushed for enactment of a host of reform measures, among them Medicare and in one of his earliest speeches to Congress referred to Medicare as “one of his top priorities”.

Back and forth it went between committees and candidates and then the November election proved decisive in the history of Medicare. President Johnson’s campaign underscored the importance of extending social security benefits to cover health care costs, but his challenger, Barry Goldwater was adamantly opposed to the plan.

Again, we had many congressional supported the measure, while at the same time organized medicine devoted great sums of money in their attempt to defeat Medicare’s chief defenders. This was an interesting election which proved to be a win for the Democrats, who gained thirty-eight seats in the House and the pro-Medicare majority increased by forty-four seats. Also, interesting was that of the fourteen physicians who ran for Congress in the election eleven lost, and of those three that won one was a Medicare supported.

It seemed obvious that the electoral outcome was due in a large part to the strong support given the pro-Medicare candidates by the older voters. The prominence given the prospective passage of a Medicare bill during the campaign led to its being given “pride-of-place in the 89thCongress. Next, the King-Anderson bill was the first bill introduced into each chamber (H.R. 1 and S.1) when Congress convened on January 4, 1965. President Johnson 3 days later, in a Special Message to Congress, urged the swift passage of the bill.

It was interesting that the bill was only a hospital insurance scheme only and did not cover physicians’ services. The AMA was faced with a choice of whether to support the bill or help design a modified bill to Organized medicine’s liking. The AMA then proposed an alternative called the “Eldercare” bill, that would have expanded the Medical Assistance (MAA) for the Aged program, which was established under the Kerr-Mills Act. Then two members of the Ways and Means Committee introduced legislation along the lines of Eldercare, which provided more sweeping coverage than the King-Anderson bill.

The AMA’s campaign seemed to strike a sympathetic chord among the electorate and a survey by the AMA found that 72% of the respondents agreed that any government health insurance plan should cover physicians’ services. The Congressional backers of a government health insurance plan were delighted with the poll, which signaled wide support for an extension of coverage offered by the King-Anderson bill.

Here we go again, the Republicans were worried of being deprived of not getting any credit for a health insurance plan and so a third bill was introduced in the Ways and Means Committee by its ranking Republican member, John Byrnes of Wisconsin. This plan was an extension of a private health insurance plan offered by the Aetna Life Insurance Company to federal employees. This plan called for the creation of a government-administered insurance plan for the elderly that covered both hospital expenses but also physicians’ services as well as the costs of drugs and permitted older Americans to either opt out of the plan or not, their choice.

It gets more complicated but Wilbur Mills the Committee Chairman thought that combining the most ambitious components of all three bills into a new proposal would be best.

More to come next week!

This Sunday being Father’s Day, I decided to write a blog post on the word “father.”

While that may seem like an obvious idea, there’s a deeper meaning to that word for me personally—since 2017, the word “father” has been my life word.

You see, for years—decades, really—I have prayed for and selected a word that would lead me to live intentionally throughout the calendar year. I’ve chosen words or phrases that would spur my thinking and my actions to be in alignment with the kind of life I want to live.

Some years the word was intensely personal, usually because I had a lot of growing to do in a specific area. Other years, the word was more about others and how I needed to add value to people in new ways.

But “father” is different.

I thought it would be a one-year word, a gentle reminder to see and connect with people with even greater care and wisdom. But one year turned into two, and I began to understand that some people don’t need care and wisdom—they need a dose of reality to get them moving!

Then, two years became three.

This is my third year with the word “father” as the central piece of my thinking and reflection, and I’ve become more convinced it may be my word for the rest of my life.

Part of that sense comes from the work I’m doing with my team. We’re experiencing a season of significance unlike anything I’ve ever seen—the culmination of their tireless work over the years and miles of this leadership journey. We are collectively seeing a harvest on seeds we’ve sown at times and in places when we weren’t sure there’d ever be a return.

The joy and fulfilment of reaping those rewards with the many wonderful people I’ve worked and coached alongside is deeper and richer than I could’ve dreamed. Fatherhood, in this instance, is fun.

But there’s also the flipside of being a “father” to many, and I’m reminded of it whenever I visit places where people are desperate for training in values and leadership. More and more, people are asking for help in transforming themselves and their communities, and more and more I find my heart and my passion drawn to help them.

I want to be a guide; be a friend; be a teacher; be a mentor.

But what I really want to be is a “father”.

“Father” is about adding value differently, which means I am constantly stretching myself in new ways. Just like when my kids were growing up, and I had to change tactics or reset my thinking, I’m finding that being a “father” to many means constantly adjusting how I approach life.

My thinking is deeper, bigger, more inclusive, more defined; as a result, my dreams are larger and more significant than I ever imagined because they are dreams for other people.

That’s what it means to be a “father”. That’s what my dad did for me—he dreamed big dreams on my behalf and then loaned me his belief to chase dreams of my own. I am blessed that he’s still with me; this will be our 72ndFather’s Day together, and every year reminds me of how wonderful it is to have my father’s love and investment.

It also reminds me to pay that kind of love forward.

In that way, the biggest gift of a “father” is to pour into others what is valuable and good and helpful and challenge them to repeat the process with others. The influence of a father can either build or destroy, and our world needs more of the former. We have more than enough of the latter.

My challenge to you this Father’s Day is to add value to someone else. Invest in them, encourage them, challenge them; loan them your belief in their potential, and then equip them to do something amazing with it.

I’ve seen firsthand how that kind of intentional investment changes families, as well as changes the world.

Happy Father’s Day to you, wherever you are. Whether you’re celebrating or being celebrated, make it a day to remember—make it a day that you choose to add value to others and make a difference to those around you.

Critical condition: The crisis of rural medical care, Guns and Knives and Medicare!

d day257[1467]I wanted to start with this article because our rural area of Maryland is going through the same scenario. We had 3 hospitals serving the mid and upper Delmarva Peninsula but 2 of the hospitals were barely making ends meet. In fact, one of the hospitals will be closed down replaced by an enlarged Urgent care type of facility. Another needs to be shut down and reconfigured as a stabilizing/urgent care center. This last hospital sometimes has an in-hospital census of 1 or 2 patients. You can’t pay the bills with that census and how do you pay your staff, keep the heat and air conditioning and electric running?

Tonopah, Nevada, is about as isolated a place as you can find – 200 miles south of Reno, 200 miles north of Las Vegas, with one road in or out. But to those who call it home, this scenic dot on the desert landscape once had everything they needed.

Emmy Merrow had no concerns about living in such a remote place: “It had a store and a gas station, and I was fine!” she laughed.

Merrow has lived here for four years. She has a two-and-a-half-year-old, Aleyna, and a newborn daughter, Kinzley.

They moved here when her husband got a great job offer from the sheriff’s department. But six weeks before she found out she was pregnant with Aleyna, she also found out Tonopah’s struggling hospital, its only hospital was shutting its doors for good.

“I’m frustrated, I’m mad, I cry, I’m upset about it because we would live less than a mile away from a hospital,” she said.

It was all the more worrisome when, shortly after she was born; Aleyna was diagnosed with Dravet Syndrome, a catastrophic form of epilepsy. “She’s just like any other typical kid, and our day is just like any other day, except for when she has seizures,” Merrow said.

“And how many does she have a day?” asked correspondent Lee Cowan.

“She’s at about 400 now.”

“So, is there anybody within a reasonable distance that can help?

“No.”

When the seizures are bad enough, which is about every six weeks or so, Merrow has to make a mad, desolate dash to the closest hospital, which is across the border in California, some 114 miles away.

She’ll never forget the first time she had to do it: “It was in the middle of the night, so it was dark and I couldn’t see her, so I did stop quite often to just check and make sure she was still breathing.”

“That must have been terrifying,” Cowan said.

“Yeah, I was sobbing the whole way. It is the worst feeling in the world.”

Elaine Minges lives in Tonopah, too. She came here with her husband, Curt, for a high-paying job at the nearby solar plant, and thought they’d retire here one day. “We knew that there was a hospital here and there were a few physicians, and we felt comfortable at the time,” Minges said.

But after the hospital closed, everything changed. “They shut the doors and that was it,” she said.

“And they didn’t give you any warning?”

There were rumors, she said, but “we thought no, that won’t happen. That doesn’t happen. Look, we’re out in the middle of nowhere!”

Curt, who had diabetes, tried not to think about it until one night he suddenly fell very ill. Minges recalled, “He woke up and I thought he was having a heart attack. He was gasping for air. He tried to get up, but he was just too sick.”

He was suffering a serious complication from diabetes. It’s a condition normally survivable with prompt medical attention, but in this case, prompt meant getting a helicopter. “That particular night, the helicopter was 45 minutes out before they could get to the airport, and in that time, he went into cardiac arrest.”

Cowan asked, “Had the hospital here been open, would that have saved your husband?”

“I would like to think so, yeah.”

It’s a grim tale repeating itself all across the country.

Since 2010, 99 rural hospitals like the one in Tonopah have closed; that’s almost one a month.

“Basically about half of the rural hospitals are losing money every year,” said Mark Holmes, a professor of health policy and management at the University of North Carolina, who has been studying the decline for more than a decade.

Cowan asked, “Is there an end in sight?”

“Every time that I’ve said, ‘I think we’re through the worst of it,’ we’ve been surprised,” Holmes replied. “You always have to wonder, who’s next?”

A whole cross-section of America is now facing the very real risk of having no local hospital to turn to. The causes are varied; the population in some of those towns has dwindled to a size that can’t support a hospital anymore.

In others, the hospitals are either mismanaged or they end up as table scraps in mega-mergers. Medicaid expansion would have helped some stay open, Holmes says, but not all, and even so reimbursement rates are often too low for hospitals to break even. Whatever the cause, the impact on the community is almost always the same:

“The hospital closes, the emergency room dries up, all the other services that went with that – home health, pharmacy, hospice, EMS – they leave town as well, and now you’re left with a medical desert,” said Holmes.

That’s exactly the fate residents of Pauls Valley, Oklahoma was worried about. The town, about 60 miles south of Oklahoma City, has only one hospital, but the previous management company had run it into bankruptcy.

The city brought in Frank Avignone to save it. When Cowan visited, Avignone was working the phones to find a generous donor to keep it open: “I’ve got 130 employees here that I’m going to have to tell they have no future,” he said.

“It’s literally day-by-day for this hospital,” Cowan asked.

“It’s minute-by-minute,” he replied.

“How much money do you have in the bank right now?”

“About $7,000.”

“Which gets you how far?”

“The next 15 minutes. I mean, it’s not enough to really make a difference.”

Townspeople rallied, especially those who had been treated here, like Susanne Blake. She and her husband pitched in half of their retirement savings – a gamble that to them, made some good-natured sense. “We got tickled about how much we should give, because he said, ‘Well, without a hospital, we don’t have to worry about as long a retirement!'” she laughed.

Employees were just as passionate. Linda Rutledge, who’s worked in the hospital’s cafeteria for nearly 20 years, baked over a thousand cookies – a bake sale with a lot riding on it.

Asked what will happen should the hospital close, Rutledge replied, “I’m going to cry. That’s just can’t happen.”

But it can happen. And last year, in response to the need for medical care, a massive free health clinic popped up at a fairground in Gray, Tennessee, set up by a non-profit called Remote Area Medical – originally founded to serve third-world countries.

But Chris Hall, the charity’s COO, says a rural hospital closure back in 1992 forced the organization to address the medical needs of the underserved here at home, too.

“Today alone, there’s seven states’ worth of patients that have come to this event,” Hall said. “People have gotten in their car and driven 200 miles to get here today just to be able to get a service that they couldn’t get in their local area, or [couldn’t] afford in their local area.”

Some who lined up overnight in the cold did, in fact, have a hospital; they just didn’t have the insurance to access it. But for others, like Leanna Steele, this is the closest thing they have to an emergency room. Her local hospital, which she used to go to when she got debilitating migraines, also closed.

Cowan asked, “So, what do you do now?”

“Mainly just sit and hope,” Steele said.

Usually, before a hospital closes entirely, administrators will try cutting back on non-emergency services, like maternity wards. That’s happened so often that more than half the rural communities in this country now no longer have labor and delivery units, leaving expectant mothers facing long drives at the worst of times.

  • But in Lakin, Kansas, population 2,200, they tried something different. The only hospital for miles decided to invest in obstetric care instead, the thinking being that babies can be a growth industry. They get patients in the door, and just as Kearny County Hospital’s young CEO Ben Anderson had hoped, they stay … and bring along the rest of the family, too.

“Moms came here and had a great experience, and they said, ‘You know, you’re gonna be my baby’s pediatrician, and you’re gonna be my women’s health physician, and you’re gonna take care of my husband as an internist. We’re all coming to you,'” said Anderson.

And that’s just what’s happened. Dr. Drew Miller has a bulletin board outside his office with pictures of the future patients he’s brought into this world – almost 500 in the last eight years, from all across the state.

“The most rewarding thing of what I get to do is to take care of families of multiple generations,” Dr. Miller said. “I could tell you stories of people I’ve delivered their babies, and taken care of their grandma or their great-grandma. That’s what I love about what I get to do here.”

And another thing: There are no high-priced specialists employed here, not even an OB-GYN. Instead, the hospital is staffed entirely by physicians trained in full-spectrum family medicine instead. “We determined we only have so many dollars to spend at a rural critical access hospital on medical care staff coverage, so it’s important that everybody is trained to do the same thing, and it’s important that everyone is willing to do it equally,” Anderson said.

A typical day for these rural doctors can include doing a colonoscopy in the OR in the morning and removing a skin lesion at a clinic in the afternoon. It’s a flexible, can-do approach to rural medicine that has kept these hospital doors open – at least for now.

“This last year we had the first profitable year in probably two or three decades,” said Anderson. “But we’re riding very, very close. We don’t have the margin for mistakes.”

It’s that razor’s edge that hospitals like the one back in Pauls Valley, Oklahoma, had ridden for too long. Cowan was there when CEO Frank Avignone brought the staff together to share some news: “You can only live on borrowed time so long,” he said. The hospital was closing, immediately.

“I’m not sure people really understand what’s going on,” Avignone told Cowan. “The story’s gotta get out. People have to see the faces of the folks in this community and the employees and what they’ve been through. People die because this hospital won’t be open.”

Back in Tonopah, Nevada, Emmy Merrow understands those risks firsthand after one excruciatingly long drive to a hospital with Aleyna that had irreversible consequences. “She fell into a seizure that lasted three hours long; it lasted the whole entire trip,” she said. “So, she has brain damage from that. She wasn’t breathing correctly, she lost oxygen.”

“I think people watching this are going to wonder if it’s that bad, and you’re so far away from a hospital, and you need help basically all the time, why not move?” asked Cowan.

“It would be great if we had the money to be able to move,” she replied. “We make enough to live, but not really enough to save up to be able to make that move.”

As for Elaine Minges, with her husband now gone, the rural life they loved so much is gone, too, and like so many who live in small-town America, she’s at a loss for what to do next.

Cowan asked, “Will you stay here knowing there’s not a hospital?”

“My home is here,” she said. “I feel my husband here.”

“What do you think he’d want you to do? Would he want you to stay?”

“No,” she said.

Right now, we all in our community are considering alternatives and more and more of our patients are going “across the bridge” to University or “better” hospitals. I suspect that this is going to be more of a problem in the future with more talk of Medicare for All.

These next two discussions are in response to a local senseless stabbing/murder in our small town. We were lucky that the murderer wasn’t carrying a gun or the deceased could have numbered in a much higher amount.

Angry young white men charged in America’s latest mass shootings

Annalisa Merelli noted that there have been 25 mass shootings in the US this year. Seventeen of the incidents were deadly and 11 killed three to five victims each—for a total of 45 fatalities.

Last week alone, 17 people (not including the shooters) lost their lives in four mass shootings. Three of the attacks were said to be carried out by 21-year-old white men:

  • Zephen Xaver allegedly shot and killed five women in the lobby of a SunTrust bank branch in Sebring, Florida on Jan. 23.
  • Jordan Witmer killed three in State College, Pennsylvania on Jan. 24.
  • Dakota Theriot has been charged with killing five: his girlfriend, her brother, her father, and both of his own parents in Livingston Parish and Baton Rouge, Louisiana on Jan. 25.

Investigators are still looking into motives yet it’s hard not to note some commonalities: All of these mass shooters were men, and they all targeted women. They had shown violent behavior and tendencies in the past or had been exposed to violence. None of this seemed to have stopped them from being able to acquire guns. It’s an all-too-familiar pattern in the US. The shooters’ identities are also consistent with the overall American trend: Mass shootings are nearly exclusively perpetrated by men, the vast majority of whom are white.

Xaver, ex-girlfriend Alex Gerlach told WSBT-TV, “for some reason always hated people and wanted everybody to die” and “got kicked out of school for having a dream that he killed everybody in his class, and he’s been threatening this for so long.” Gerlach said her warnings about Xaver were not taken seriously, even as he bought a gun it was not considered a warning sign. After the shooting, police chief Karl Hoglund described the targeting of five women a “random act.” Amongst Xaver’s interests were prominent right-wing figures such as Milo Yannopoulos and Alex Jones; when he was arrested, he was wearing a T-shirt with a print of the Four Horsemen of the Apocalypse, the New Testament figures of destruction.

Witmer, the Pennsylvania shooter, also took aim at a female victim. He was having drinks with Nicole Abrino, a woman identified a current or former girlfriend when the two argued. Dean Beachy, who was sitting across the bar, tried to break up the fight. Witmer shot him in the head, killing him, then fatally shot Beachy’s son. Witmer also shot Abrino, who survived. Witmer left the bar, later crashing his car and breaking into a home where he shot and killed a fourth person. He then killed himself. Witmer, who didn’t have a history of violent behavior, had recently returned from a three-year stint with the US Army. According to his family, he was planning to become a police officer.

Theriot, targeted his girlfriend of about two weeks, Summer Ernest, police said, and the murder in Louisiana seemed premeditated. The young man was living with Ernest and her family after he had been kicked out of his own home. He is said to have shot her dead, followed by her father and younger brother. Theriot then took the father’s truck, and drove to his parents’ home, police said, killing both of them. He was arrested as he tried to reach his grandmother, still carrying a gun. Theriot, his neighbors said, had a history of trouble with drugs and he had been arrested for minor drug possession. Though authorities say he didn’t have a history of violent behavior, some who knew him to seem to disagree. They say he had pulled a gun out on his mother, which was among the reasons he had been kicked out of the house.

ACCORDING TO THE FBI, KNIVES KILL FAR MORE PEOPLE THAN RIFLES IN AMERICA – IT’S NOT EVEN CLOSE

Columnist Benny Johnson noted that knives kill far more people in the United States than rifles do every year.

In the wake of the horrific school shooting in Florida last week, the debate over guns in America has surged again to the forefront of the political conversation. Seventeen students were killed when a deranged gunman rampaged through the Stoneman Douglas High School in Parkland Florida. Many are calling now for stricter gun laws in the wake of the shooting, specifically targeting the AR-15 rifle and promoting the reinstatement of the assault weapons ban.

However, recent statistics from 2016 show that knives actually kill nearly five times as many people as rifles that year.

According to the FBI, 1,604 people were killed by “knives and cutting instruments” and 374 were killed by “rifles” in 2016.

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The statistics match the trends seen in previous years, which show knife murders far outnumbering rifle statistics. In 2013, knives were used to kill 1,490 and rifles were used to kill 285. Handguns far outnumber both knives and rifles in American murders. There were 7,105 murders by handgun in America in 2016.

Handguns were not included in the assault weapons ban.

Writing on the issue of handgun violence, The Federalist makes this interesting point:

“But what about handgun murders?” you might ask. “They’re responsible for the majority of gun murders, so why don’t we just ban them and stop worrying about rifles?”

Easy: because gun bans and strict gun control don’t really prevent gun violence. Take, for example, Illinois and California. In 2013, there were 5,782 murders by handgun in the U.S. According to FBI data, 20 percent of those — 1,157 of the 5,782 handgun murders — happened in Illinois and California, which have two of the toughest state gun control regimes in the entire country. And even though California and Illinois contain about 16 percent of the nation’s population, those two states are responsible for over 20 percent of the nation’s handgun murders.

One of the difficulties in the FBI’s statistics is the pinpointing of the exact type of firearm used in the overall number of gun murders. In over 3,000 cases, the firearm is not “stated.” This means it could be a rifle, handgun or shotgun used in the crime.

Certainly, this could potentially add to the number of rifle deaths each year. However, if the ratios of weapons used in the uncategorized 3,000 number reflected the overall sample size, the number of rifle deaths would only rise by a small fraction, not nearly enough to surpass the number of knife deaths.

So, what next? Do we outlaw guns as well as knives? What do we use as cutting utensils……plastic knives????

And More About the Medicare Story!

For Medicare, the best progress was made thanks to Presidential candidate John F Kennedy. Kennedy along with Clinton P. Anderson of New Mexico, introduced a measure similar to the previous Forand bill in the Senate the summer of 1960. The measure was defeated in favor of the Kerr-Mills bill, but the Democratic platform contained a provision supporting an extensive hospital insurance strategy for the aged. Kennedy made this proposal a subject of his speeches during his stumping for the presidency and even before his administration took office a White House Conference on Aging again brought the issue of a government health insurance. They seemed to get more and more support, especially since Eisenhower’s Secretary of Health, Education, and Welfare was among several prominent Republicans who were in support of the enactment of a comprehensive measure.

Almost immediately following his inauguration, on February 9, 1961, President Kennedy sent a message to Congress calling for an extension of the social security benefits to cover hospital and nursing home costs. The bill would have covered 14 million recipients over the age of sixty-five was predicted to cost approximately a billion and a half dollars, but didn’t include the cost of medical or surgical treatment. It only covered for ninety days of hospital care, outpatient diagnostic services and a hundred and eighty days of nursing home care. Imagine the cost back then of adding on the medical and surgical treatment costs!

Because of Kennedy’s thin margin of victory in November, it was deemed expedient not to press for passage of the bill until the following year. But along comes the AMA creating the American Medical Political Action Committee, which was joined with the commercial health insurance carriers and Blue Cross-Blue Shield in opposing the bill and questioned the cost put forward by the administration. The opposition mounted a strong campaign against the King-Anderson using posters, pamphlets and radio, and TV extensively. The Association seemed to be angered by included fee schedule for hospitals, nursing homes, and nurses which could serve as a precedent should government insurance be expended to include.

There was a great deal of fighting as the Kennedy administration demonized the AMA, accusing the association of thwarting the public will with the interest of lining the pockets of its membership and of employing scare tactics against the government’s interest and only concern to extend to the aged and infirm needed medical benefits. The administration got support from organized labor and several new organizations which lobbied extensively in favor of the measure.

On and on went the supporters and the opposition until finally after Kennedy’s assassination when Congressional support for Kennedy’s legislation swelled, but that is for another day and next week.

And an impressive celebration of D-day. Thank you again Veterans who fought for us all!!

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

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

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

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

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

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

It’s unclear what caused the officers’ illnesses.

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

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

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

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

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

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

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

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

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

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

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

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

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

So, what about using barbers as our physicians?

Will Barbers Regain Their Role as Medical Practitioners?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Families list health care as a top financial problem: poll

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

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

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

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

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

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

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

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

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

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

Medicare and healthcare reform

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

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

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

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

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

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

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

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

More next week.

The Conversation We Refuse to Have About War and Our Veterans, Hospital Billing and More on the History of Medicare.

Screen Shot 2019-05-26 at 11.34.05 PMMemorial Day and the latest redeployment of soldiers and a carrier group to the Middle East is a perfect time to realize that Veterans bear the burden of war long after they leave the battlefield. It’s time for America to acknowledge it.

I went to the market

Where all the families shop

I pulled out my Ka-bar

And started to chop

Your left right left right left right kill

Your left right left right you know I will

-Military cadence

“You can shoot her…” the First Sergeant tells me. “Technically.”

Benjamin Sledge wrote reflecting, we’re standing on a rooftop watching black smoke pillars rise from a section of the city where two of my teammates are taking machine gun fire. Below, the small cluster of homes we’ve taken over is taking sporadic fire as well. He hands me his rifle with a high powered scope and says, “See for yourself.”

It’s the six-year-old girl who gives me flowers.

We call her the Flower Girl. She hangs around our combat outpost because we give her candy and hugs. She gives us flowers in return. What everyone else at the outpost knew (except for me, until that day) was that she also carried weapons for insurgents. Sometimes, in the midst of a firefight, she would carry ammunition across the street to unknown assailants.

According to the rules of engagement, we could shoot her. No one ever did. Not even when the First Sergeant morbidly reassured them on a rooftop in the middle of Iraq.

Other soldiers didn’t end up as lucky.

Sometimes they would find themselves paired off against a woman or teenager intent on killing them. So they’d pull the trigger. One of the sniper teams I worked with recounted an evening where he laid up a pile of people trying to plant an IED. It was a “turkey shoot,” he told me laughing. But then he got quiet and said, “Eventually they sent out a woman and this dumb kid.” I didn’t need to ask what happened. His voice said it all.

I often wonder what would have happened if the Flower Girl pointed a rifle at me, but I’m afraid I already know. The thought didn’t matter anyway. There was enough baggage from tours in Afghanistan and Iraq that coming home was full of uncertainty, anger, and confusion — and not, as I had been led to believe, warmth and safety.

“People only want to hear the Band of Brothers stories. The ones with guts and gusto! Not the one where you jam a gun in an old woman’s face or shoot a kid.” I pause, then add, “Look around the room for a second…”

Andy surveys the restaurant we’re in for a moment while I lean in with a sardonic half-smile.

“How many people can even relate to what we’ve been through? What would they rather hear about? How Starbucks is giving away free lattes and puppies this week? Or how a soldier feels guilty because he pulled a trigger, lost a friend, or did morally questionable things in war? Hell, I want to hear about the latte giveaway… especially if it’s pumpkin spice.”

This eases the tension and he smiles.

Andy and I feel like we don’t fit in. We met a few years ago at the church where he works, and where I volunteer. Of the thousands of people in the congregation, we are a handful of veterans. The veterans I meet are few and far between, and we typically end up running in the same circles.

How do you talk about morally reprehensible things that have left a bruise on your soul?

Years ago, Andy fought in the siege of Fallujah. We never readjusted to normal life after deployment. Instead, we found ourselves angry, depressed, violent and drinking a lot. We couldn’t talk to people about war or its cost because, well, how do you talk about morally reprehensible things that leave a bruise on your soul?

The guilt and moral tension many veterans feel is not necessarily post-traumatic stress disorder, but a moral injury — the emotional shame and psychological damage soldiers incur when we have to do things that violate our sense of right and wrong. Shooting a woman or child. Killing another human. Watching a friend die. Laughing about situations that would normally disgust us.

Because so few in America have served, those who have can no longer relate to their peers, friends, and family. We fear being viewed as monsters or lauded as heroes when we feel the things we’ve done were morally ambiguous or wrong.

The U.S. is currently engaged in the longest running war in the history of the United States. We are entering our 15th year in Afghanistan, and we still station troops in some Iraqi outposts. In World War II, 11.5% of U.S. citizens served in four years. In Vietnam, 4.3% served in 12 years. Since 2001, only 0.86% of our population has served in the Global War on Terror. Yet, during World War II, 10 million men were drafted, and over 2 million men were conscripted during Vietnam. Despite the length of the Iraq and Afghan Wars, there has been no draft, whereas, in times past, shorter wars cost us millions of young men. Instead, less than 1% of the population has borne this burden, with repeated tours continually deteriorating our troops’ mental health.

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The gap between citizens and soldiers is growing ever wider. During WWII, the entire nation’s focus was on purchasing war bonds and defeating the Nazis. Movie previews and radio shows gave updates on the war effort. Today’s citizens, however, are quickly amused by the latest Kardashian scandal on TV, which gives no reminder of the men and women dying overseas. Because people are more concerned about enjoying their freedoms and going about their day to day lives, veterans can feel like outcasts. As though nothing we did matter to a country that asked us to go.

This is part of the problem with a soldier’s alienation. People quickly point out that we weren’t forced to join the military and fight in a war. We could have stayed home. The counterpoint is that, because the U.S. has now transitioned to an all-volunteer force, those opposed to war should be thanking their lucky stars that volunteers bear the burden of combat.

Additionally, regardless of whether you’re Republican, Democrat, Libertarian, Communist, Liberal, Conservative, Conscientious Objector, or Pacifist, we all sent the soldier overseas. Because we live in a democracy, we vote to put men and women in charge of governing our affairs, and those elected representatives send troops overseas. We may have voted for someone else, but it does not change the fact that we’ve put ourselves under the governance of the United States. When you live in a country, you submit yourself to their governing body and laws — even if you don’t vote.

The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place.

By shirking responsibility, civilians only alienate our soldiers more. The moral quagmire we face on the battlefield continues to dump shame and guilt onto our shoulders while they enjoy the benefits of passing the buck and asking, “Whose fault is it, really?”

On March 3, 1986, 11 years after the end of the Vietnam War, Metallica released their critically acclaimed album Master of Puppets. On the album, a song entitled “Disposable Heroes” tells the story of a young man used as cannon fodder in the midst of war and the terror that enveloped him on the battlefield. Three years later, Metallica released “One,” a song about a soldier who lost all his limbs and waits helplessly for death. The song won a Grammy for Best Metal Performance.

In an odd twist, both songs are amazingly popular among members of the United States military. During my time at the John F. Kennedy Special Warfare Center, we had an entire platoon that could practically sing every last lyric to “One.” In Afghanistan and Iraq, these songs were on playlists made to get soldiers amped before missions. We sang songs about dying on behalf of the people or coming home a vegetable. As crazy as that sounds, we sang those songs because they felt true. And they felt true because of the conversation we refuse to have as a country.

As Amy Amidon, a Navy psychologist stated in an interview regarding moral injury:

Civilians are lucky that we still have a sense of naiveté about what the world is like. The average American means well, but what they need to know is that these [military] men and women are seeing incredible evil, and coming home with that weighing on them and not knowing how to fit back into society.

Most of the time, like the conversation Andy and I had, people only want to hear the heroics. They don’t want to know what the war is costing our sons and daughters in regard to mental health, and this only makes the gap wider. In order for our soldiers to heal, society needs to own up to its part in sending us to war. The citizen at home may not have pulled the trigger, but they asked the soldier to go in their place. Citing a 2004 study, David Wood explains that the “grief over losing a combat buddy was comparable, more than 30 years later, to that of a bereaved spouse whose partner had died in the previous six months.” The soul wounds we experience are much greater. Society needs to come alongside us rather than pointing us to the VA.

Historically, many cultures performed purification rites for soldiers returning home from war. These rites purified a broad spectrum of warriors, from the Roman Centurion to the Navajo to the Medieval Knight. Perhaps most fascinating is that soldiers returning home from the Crusades were instructed to observe a period of purification that involved the Christian church and their community. Though the church had sanctioned the Crusades, they viewed taking another life as morally wrong and damaging to their knights’ souls.

No one in their right mind wants war. We want peace. And no one wants it more than the soldier.

Today, churches typically put veterans on stage to praise our heroics or speak of a great battle we’ve overcome while drawing spiritual parallels for their congregation. What they don’t do is talk about the moral weight we bear on their behalf.

Dr. Jonathan Shay, the clinical psychologist who coined the term moral injury, argues that in order for the soldier and society to find healing, we must come together and bear the moral responsibility of what soldiers have done in our name.

Whether you agree or disagree with the war, you must remember that these are our fellow brothers and sisters, sons and daughters, flesh and blood. As veterans, we are desperate to reconnect with a world we feel no longer understands us. As a country, we must try and find common ground. We’re not asking you to agree with our actions, but to help us bear the burden of carrying them on behalf of the country you live in. A staggering 22 veterans take their lives every day, and I can guarantee part of that is because of the citizen/soldier divide.

But what if it didn’t have to be this way? What if we could help our men and women in uniform bear the weight of this burden we carry? We should rethink exactly what war costs us and what we’ve asked of those who’ve fought on our behalf. In the end, no one in their right mind wants war. We want peace. And no one wants it more than the soldier. As General Douglas MacArthur eloquently put it:

“The soldier above all other people prays for peace, for he must suffer and bear the deepest wounds and scars of war.”

And what do we offer our Veterans for their healthcare when they come home? A truly horrid attempt at a government-run healthcare system, which now is pushing to get our Vets to private healthcare programs!!

Surprise! House, Senate Tackle Hospital Billing

Senate bill also addresses provider directories, drug maker competition

Our friend Joyce Frieden wrote that responses are generally positive so far regarding draft bipartisan legislation on surprise billing and high drug prices released Thursday by the Senate Health, Education, Labor, and Pensions (HELP) Committee.

“We commend this bipartisan effort to address several of the key factors associated with rising health care costs,” Richard Kovacs, MD, president of the American College of Cardiology, said in a statement.

“We agree with and support many of the principles outlined by the HELP Committee,” Matt Eyles, president, and CEO of America’s Health Insurance Plans, a trade group for health insurers, said in a statement. “We agree patients should be protected from surprise medical bills, and that policy solutions to this problem should ensure premiums and out-of-pocket costs do not go up for patients and consumers.”

The HELP Committee draft bill, known as the Lower Health Care Costs Act, would:

  •  Require that patients pay only in-network charges when they receive emergency treatment at out-of-network facilities, and when they are treated at an in-network facility by an out-of-network provider that they did not have a say in choosing/
  • Ban pharmacy benefit managers (PBMs) from “spread pricing” — charging employers, health insurance plans, and patients more for a drug than the PBM paid to acquire the drug.
  • Require insurance companies to keep provider directories up to date so patients can easily know if a provider is in-network.
  • Require healthcare facilities to provide a summary of services when a patient is discharged from a hospital to make it easier to track bills, and require hospitals to send all bills within 30 business days, to prevent unexpected bills many months aftercare.
  • Ensure that makers of branded drugs, including insulin products, are not gaming the system to prevent generics or biosimilars from coming to market
  • Eliminate a loophole that allows the first company to submit a generic drug in a particular class to enjoy a monopoly
  • Give patients full electronic access to their own health claims information.

Although the patient will only need to pay in-network charges when receiving service from an out-of-network provider, that in-network amount won’t pay for the entire out-of-network bill, so lawmakers still must decide how to deal with the rest of the out-of-network charge. The committee says it’s considering several options, including having insurance companies pay the out-of-network providers the median contracted rate for the same services provided in that geographic area, and, for bills over $750, allowing the insurer or the provider to initiate an independent dispute resolution process. The insurer and provider would each submit a best final offer and the arbiter would make a final, binding decision on the price to be paid.

The bill’s provisions “are common-sense steps we can take, and every single one of them has the objective of reducing the health care costs that you pay for out of your own pocket,” committee chairman Lamar Alexander (R-Tenn.) said in a statement. “We hope to move it through the health committee in June, put it on the Senate floor in July and make it law.” The bill is co-sponsored by Sen. Patty Murray (D-Wash.), the HELP Committee’s ranking member.

Over on the House side, legislators also released a bipartisan bill Thursday on surprise billing. This bill, known as the Protect People From Surprise Medical Bills Act, mirrors the Senate bill in prohibiting balance billing to patients receiving emergency care out of network or anticipated care at in-network facilities that use out-of-network providers without the patient’s knowledge or consent.

The patient would pay in-network rates in those situations, and then the health plan would have 30 days to pay the provider at a “commercially reasonable rate.” If either party is dissatisfied with that rate, the plan and doctor would settle on a payment amount; if that didn’t work, the parties could go to arbitration.

This legislation “will ban these bills and keep families out of the middle by using a fair, evidence-based, independent, and neutral arbitration system to resolve payment disputes between insurers and providers,” Rep. Raul Ruiz, MD (D-Calif.), the bill’s main sponsor, said in a statement. “As an emergency doctor, patients come first and must be protected.”

Co-sponsors of the bill include representatives Phil Roe, MD (R-Tenn.), Donna Shalala (D-Fla.), Joseph Morelle (D-N.Y.), Van Taylor (R-Texas), Ami Bera, MD (D-Calif.), Larry Bucshon, MD (R-Ind.), and Brad Wenstrup (R-Ohio). The group expects to introduce the final legislation in the next few weeks.

The American Society of Anesthesiology (ASA) praised the House bill. “The approach to addressing the problem of surprise medical bills outlined by Congressmen Ruiz and Roe is a fair proposal that puts patients first by holding them harmless from unanticipated bills,” ASA president Linda Mason, MD, said in a statement. “The proposal doesn’t pick winners or losers but instead places the dispute where it should be — between the health care provider and the insurance company.”

The American Medical Association (AMA) also liked the bill. “The outline released today represents a common-sense approach that protects patients from out-of-network bills that their insurance companies won’t pay while providing for a fair process to resolve disputes between physicians and hospitals and insurers,” AMA president Patrice Harris, MD, said in a statement.

Now, back to Medicare and the history of healthcare reform. Next, there was a convening of a National Health Conference, which had earlier approved a report of its Technical Committee on Medical Care, urging a huge extension of federal control over health matters. Sound familiar? Here we are in 2019 urging more control of the federal government over health care again in the form of a government-run health care system as either Obamacare or Medicare for All. The conference in 1938 opened with a statement by President Roosevelt describing the ultimate responsibility of the government for the health of its citizens.

The “technical committee” advised the Conference recommended that the federal government enact legislation in several areas:

  1. An expansion of the public health and maternal and child health programs including the original Social Security Act.
  2. A system of grants to the various states for direct medical care programs.
  3. Federal grants for hospital construction.
  4. A disability insurance program that would insure against loss of wages during illness.
  5. Grants to the states for the purpose of financing compulsory statewide health insurance programs.

The total costs of the program were about $850 million tax-funded and now compare this to the cost of Medicare for All at about $34 trillion. We should have adopted Medicare for All then. We would have saved a boatload of money.

It was interesting to learn that in order to placate the majority of medical practitioners the Committee urged the adoption of these programs on the state level. The reason why physicians opposed a program on the national level was the fear of becoming government salaried employees with not much to say in the administration of the program.

As predicted in 1943 when Senator Robert Wagner of New York, together with Senator James Murray of Montana and Representative John Dingle of Michigan, introduced a bill, which called for compulsory national health insurance/ mandatory health insurance as well as a federal system of unemployment insurance, broader coverage and extended benefits for old-age insurance, temporary and permanent disability payments underwritten by the federal government, unemployment benefits for veterans attempting to reenter civilian life, a federal employment service, and a restructuring of grants-in-aid to the states for public assistance.

Roosevelt wasn’t against the bill but he wasn’t prepared to endorse a bill quite so sweeping and so the bill dies in committee. But interestingly Roosevelt wanted to save the issue of national health care for the next presidential campaign in 1944. During the campaign he then called for an “Economic Bill of Rights,” which would include “the right to adequate medical care and the opportunity to achieve and enjoy good health” and the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment” and in his budget message of January 1945 he announced his intention of extending social security to include medical care.

However, Roosevelt died in April 1945 and then Harry Truman took over the presidency committed to most of the same domestic policies as Roosevelt. But then came politics and party and the attempts to enact a health insurance bill during the Truman era came to a definite end with the election of 1950 where a number of the proponents of the mandatory national health insurance were defeated as well as a vigorous and costly campaign by the American Medical Association which was against compulsory health insurance associating the plan in the mind of the public with notions of socialism. Sound familiar?

More next week!

Let us all thank our veterans, our heroes, our real Avengers for all that they have done to assure us all of living in such a great free country. Happy Memorial Day!!

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Health Insurance Inflation Hits Highest Point in Five Years and More on Medicare; and What is this about Abortion and SATs?

57358059_1998437466952569_3700281945192660992_nFirst of all, I must yell and scream at the idiots in the States, you know who you are, that have or are in the process of passing the most restrictive abortion bills. This is especially Alabama where Governor Kay Ivey signed the strictest anti-abortion law. Legislation to restrict abortion rights has been introduced in 16 states this year. The Alabama Senate approved a measure on last week that would outlaw almost all abortions in the state, setting up a direct challenge to Roe v. Wade, the case that recognized a woman’s constitutional right to end a pregnancy. The legislation bans abortions at every stage of pregnancy and criminalizes the procedure for doctors, who could be charged with felonies and face up to 99 years in prison. It includes an exception for cases when the mother’s life is at serious risk, but not for cases of rape or incest — a subject of fierce debate among lawmakers in recent days. The House approved the measure — the most far-reaching effort in the nation this year to curb abortion rights and was just signed by the Governor.

What the heck are you thinking, not even for rape or incest? You are forgetting the women who bare the brunt of your idiot decisions. Do you think that the Supreme Court will overturn Roe versus Wade, passed in 1973? Get real and attend to the real multiple crises out there!

And diversity scores on the SAT exams??? Again, what are you all thinking? I know to correct the “crises of rich parents who got their “unfortunate” children into the best of colleges. Next, the strategy to get our children into good colleges will be to take courses to improve their test-taking abilities, but now they will have to figure out how to improve their adversity scores. Mom and Dad, we need to move into the ghettos of Scarsdale, get on food stamps, get fired from your high paying jobs and become homeless. I know this all sounds crazy, but that is where we are.

Shelby Livingston wrote that the health insurance inflation rate hit a five-year peak in April, possibly because managed care is rising.

The Consumer Price Index for health insurance in April spiked 10.7% over the previous 12 months—the largest increase since at least April 2014, according to a Modern Healthcare analysis of the U.S. Bureau of Labor Statistics’ unadjusted monthly Consumer Price Index data.

In contrast, the other categories that make up the medical care services index—professional services and hospital and related services—rose 0.4% and 1.4% in April, respectively. The CPI for medical care services in April rose 2.3%, while overall inflation increased 2% year over year.

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Because of the way the BLS calculates the health insurance index, the change year over year does not reflect premiums paid by customers, but “retained earnings” after paying out claims. These earnings are used to cover administrative costs or are kept as profit.

The BLS redistributes the benefits paid out a portion of the health insurance index to other non-insurance medical care categories, such as physician services.

The likely reason health insurance inflation is rising is because of growth in managed care, including Medicare Advantage, Medicaid managed care and commercial insurance, according to Paul Hughes-Cromwick, an economist at Altarum. He noted that added administrative costs increase insurance price growth.

Hughes-Cromwick said the increase in the health insurance index could also be driven by the fact that insurers’ medical loss ratios may be decreasing as high premiums, particular in the individual health insurance exchanges, exceeded anticipated claims.

The medical loss ratio reflects the percentage of every premium dollar spent on medical claims and quality improvement. Insurers must pay at least 80% of premiums on those things and if they don’t, they must issue rebates to plan members, as part of the Affordable Care Act.

In response to rising inflation, a spokeswoman for America’s Health Insurance Plans, the industry’s biggest lobbying group, commented that “consumers deserve the lowest possible total costs for their coverage and care.” She pointed out the medical loss ratio requirements and said health insurers spend 98 cents of every premium dollar on medical care, operating costs that include care management, and preventing fraud, waste, and abuse.

Affordable Care Act exchange insurers hiked premiums higher than necessary in 2018 and now expect to pay out $800 million in rebates to individual market customers this year because they did not meet the medical loss ratio threshold, according to a Kaiser Family Foundation analysis published this month. Because medical loss ratios are declining, health insurers in the individual, small group and large group markets expect to issue $1.4 billion in rebates based on their 2018 performance, the analysis stated.

Still, health insurance profits have been on the rise. The eight largest publicly traded insurers posted net income of $9.3 billion in the first quarter of 2019, an increase of 29.9%. They made a combined $21.9 billion in profits over the course of 2018.

Medicaid waiver loophole sparks transparency concerns

Robert King noted that the CMS is doing a poor job in ensuring the public knows about major changes to Medicaid, including the installation of work requirements, a federal watchdog said Friday.

The Government Accountability Office’s report found that the CMS has limited transparency for amendments to existing Section 1115 waivers. That has allowed some states to score approval for their work requirements while skirting some rules, such as projecting how the changes will impact Medicaid enrollment.

The government watchdog noted that two of the four states it studied did not seek public comment on changes that could significantly impact Medicaid beneficiaries.

The transparency requirements for an amendment are more relaxed than a new waiver application, the GAO said. Arkansas and New Hampshire both added work requirements to their Medicaid programs through amendments to their existing Section 1115 waivers.

Currently, new waivers or extension requests must include whether the state thinks that enrollment will decrease and any spending changes. While amendments must address the impact on beneficiaries and explain the changes, there are fewer requirements for what information must be disseminated to the public.

The GAO also found that the CMS had inconsistent transparency requirements for amendments.

For example, the CMS determined Massachusetts’ amendment to waive non-emergency medical transportation was incomplete because the application didn’t include a revised design plan. However, the CMS-approved Arkansas’ work requirement amendment even though it did not include a revised design plan.

The GAO recommended that the CMS develop standard transparency requirements for new waivers, extension requests, and significant Section 1115 amendments.

In response, HHS said it has already implemented policies to improve transparency. GAO said those changes “do not apply to amendments.”

The CMS also lacks policies for ensuring that major changes to a pending application are transparent.

The report comes as the Trump administration is appealing a federal judge’s decision to strike down Medicaid work requirement programs in Kentucky and Arkansas.

Seven other states have received CMS approval for work requirements. Those states are Arizona, Indiana, Michigan, New Hampshire, Ohio, Utah, and Wisconsin. Another six states—Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia—have applications pending federal approval.

Industry enters new battle phase over surprise billing

Susannah Luthi reported that the knives are out over legislation to end surprise medical bills and specifics haven’t even been unveiled yet. But will this solve the problems of the healthcare crisis?

The industry is pushing back hard against a particular principle laid out by President Donald Trump last week.

The administration wants all out-of-network charges from a doctor at an in-network hospital to be wrapped into a single bill from the hospital.

How this provision will technically play out in policy is yet to be seen, as the Senate health committee plans to release its legislative package on surprise medical bills this summer.

But the administration’s position has roiled hospital groups and specialty physicians like emergency doctors, radiologists, and anesthesiologists, who don’t always share the same insurance network as hospitals and have higher than average charges.

“Untested proposals such as bundling payments would create significant disruption to provider networks and contract without benefiting patients,” American Hospital Association CEO Rick Pollack said in a statement shortly after Trump made his remarks. He reiterated the AHA’s position that all Congress needs to do is enact a ban on balance billing and leave the rest to the industry to figure out.

Specialty physicians argue that a single bill will complicate all the billing processes on the back-end with hospitals and insurers.

Dr. Sherif Zaafran, a Texas anesthesiologist, said he doesn’t see room within the White House framework for a policy he could support. He sees it as undercutting specialty physicians’ independence from hospitals. “As a patient, I think a single hospital bill on the surface sounds really good, but in the reality of how most of us practice it’s probably not very practical,” Zaafran said. “A single bill would imply you’re marrying the system for how a physician gets paid with other components that bill completely separately.”

He expects a resulting policy would end up cutting pay for both hospitals and ancillary physicians—hospitals taking a hit as they try to collect the fee and reimburse the physician, and physicians taking a hit if hospitals need to negotiate with insurers on their behalf.

“There are downstream effects that folks haven’t thought through,” Zaafran said.

But the administration’s stance shows how thinking around policy has morphed during months of scrutiny of the issue. And analysts have been documenting the trajectory of high ancillary physician charges in part to lay out the argument for payment bundles.

Discussions started last fall with an initial legislative push from a bipartisan group led by Sens. Bill Cassidy (R-La.) and Michael Bennet (D-Colo.). Cassidy and his co-sponsors introduced a draft proposal to cap out-of-network charges at a regional average. Not long after, Sen. Maggie Hassan (D-N.H.) pitched arbitration to settle disputes between insurers and providers.

As the months passed, the debate transitioned into a look at the underlying contracts between hospitals and insurers—even as policy analysts note that the problem of surprise medical bills is limited to a small number of hospitals.

Experts and economists from think tanks like the Brookings Institution, American Enterprise Institute, and the Urban Institute have weighed in, aided by data from states that have tried to curb the practice in the individual insurance markets that fall under their regulating power.

Several have warned that if lawmakers don’t handle the policy carefully, they could end up inflating overall costs, leading to higher premiums and expenses in an already costly system.

Joyce Frieden pointed out the solutions proposed by the President and hopefully most of the GOP.  President Trump announced an initiative Thursday aimed at ending the problem of surprise medical billing, in which patients undergoing procedures at in-network hospitals receive unexpectedly high bills because one or more of their clinicians was out of network.

Trump called surprise billing as I just outlined, “one of the biggest concerns Americans have about healthcare” and added, “The Republican Party is very much becoming the party of healthcare. We’re determined to end surprise medical billing for American patients and that’s happening right now.” He thanked the mostly Republican group of lawmakers who came to the White House to discuss the initiative, including Senators Lamar Alexander (R-Tenn.), Maggie Hassan (D-N.H.), Bill Cassidy, MD (R-La.), and John Barrasso (R-Wyo.) and representatives Kevin Brady (R-Texas), Devin Nunes (R-Calif.), and Greg Walden (R- Ore.).

Trump then announced guidelines that the White House wants Congress to use in developing surprise billing legislation. They include:

  • In emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. “So-called ‘balance billing’ should be prohibited for emergency care. Pretty simple,” he said
  •  When patients receive scheduled non-emergency care, they should be given a clear and honest bill up front. “This means they must be given prices for all services and out-of-pocket payments for which they will be responsible,” Trump said. “This will not just protect Americans from surprise charges, it will [also] empower them to choose the best option at the lowest possible price”
  •  Patients should not receive surprise bills from out-of-network providers that they did not choose themselves. “Very unfair,” he commented
  •  Legislation should protect patients without increasing federal healthcare expenditures. “Additionally, any legislation should lead to greater competition, more choice, and more healthcare freedom. We want patients to be in charge and in total control,” the president said
  •  All types of health insurance — large groups, small groups, and patients on the individual market should be included in the legislation. “No one in America should be bankrupted unexpectedly by healthcare costs that are absolutely out of control,” said Trump

He noted that “we’re going to be announcing something over the next 2 weeks that’s going to bring transparency to all of it. I think in a way it’s going to be as important as a healthcare bill; it’s going to be something really special.”

Also at the announcement was Martin Makary, MD, MPH, a surgical oncologist at Johns Hopkins University in Baltimore. “When someone buys a car, they don’t pay for the steering wheel separately from the spark plugs,” he said. “Yet, in healthcare, surprise bills and overpriced bills are commonplace and are crushing everyday folks … People are getting hammered right now.”

Trump also introduced two families who had experienced high medical bills. Drew Calver, of Austin, Texas, said that after a heart attack 2 years ago, “although I had insurance, I was still billed $110,000 … I feel like I was exploited at the most vulnerable time in my life just having suffered a heart attack, so I hope Congress hears this call to take action, close loopholes, end surprise billing, and work toward transparency.”

Paul Davis, MD, of Findlay, Ohio, said that his daughter was billed nearly $18,000 for a urine drug screening test. “She had successful back surgery in Houston and at a post-op visit, because she was given a prescription for narcotic pain relief — which she used as directed — the doctor said, ‘Oh, by the way, I’d like to get a urine specimen.’ Fine; she did it. A year later, a bill showed up for $17,850.”

He noted that her insurance company’s Explanation of Benefits said that the insurer would have paid $100.92 for the test had it been done by an in-network provider. “This type of billing is all too common … The problem of improper billing affects most [of] those who can afford it least. We must put aside any differences we have to work together to solve this problem.”

“Today I’m asking Democrats and Republicans to work together; Democrats and Republicans can do this and I really think it’s something [that is] going to be acted on quickly,” Trump said.

Healthcare groups responded positively to the announcement, with one caveat. “The AHA commends the Administration and Congress for their work to find solutions to this problem,” Rick Pollack, president, and CEO of the American Hospital Association (AHA), said in a statement. “The AHA has urged Congress to enact legislation that would protect patients from surprise bills. We can achieve this by simply banning balance billing. … Untested proposals such as bundling payments would create significant disruption to provider networks and contracting without benefiting patients.”

“ACEP appreciates the White House weighing in on this important issue and welcomes congressional action to address surprise medical bills,” said Vidor Friedman, MD, president of the American College of Emergency Physicians (ACEP), in a statement. “Emergency physicians strongly support taking patients out of the middle of billing disputes between insurers and out-of-network medical providers.”

“ACEP is concerned about the administration’s call for a single hospital bill,” he continued. “Such a ‘bundled payment’ approach may seem simple in theory for voluntary medical procedures. But if applied to the unpredictable nature of emergency care, this untested idea opens the door to massive and costly disruption of the health care system that would shift greater costs to patients while failing to address the actual root cause of surprise bills — inadequate networks provided by insurers.”

The president also mentioned another one of his administration’s healthcare initiatives. “We may allow states to buy drugs in other countries … because the drug companies have treated us very, very unfairly and the rules and restrictions within our country have been absolutely atrocious,” he said. “So we’ll allow [states], with certain permission, to go to other countries if they can buy them for 40%, 50%, or 60% less. It’s pretty pathetic, but that’s the way it works.”

And now back to Medicare. As you all probably remember the reason that physicians decided not to support the national plan was the confusion regarding reimbursement or payment to physicians. But the insurance companies as well as organized labor who opposed the compulsory system on the grounds that its passage would deprive the labor movement of an extremely effective issue with which to organize workers.

Also, with the entry of America into the First World War the interest in the passage of a compulsory health care bill waned. Because of the anti-German hysteria, the AALL bill opposition became more organized with the biased thoughts that mandatory health insurance was the product of a German conspiracy to impose Prussian values on America.

Renewed interest in mandatory health insurance didn’t emerge until during the New Deal as a consequence of the report of the Committee on Economic Security, the committee appointed by President Roosevelt in 1934. As the Depression worsened the President and his advisors were eager to offer an alternative social welfare package. Roosevelt and his advisors particularly those of the Committee on Economic Security advised the passage of a comprehensive social security system to include unemployment insurance, old-age security, and government-administered-health-care insurance.

The final report by the Committee on the Costa of Medical Care was issued in 1932, by the Committee under the chairmanship of Dr. Ray Lyman Wilbur who was the former Secretary of the Interior and former President of the AMA. The Committee actually concluded that the infrastructure in medicine as well as the medical services in the United States were inadequate and made recommendations for changes. And, despite the favorable climate especially among labor leaders, politicians and social scientists the President’s Committee on Economic Security recommender unemployment insurance and social security but not the passage of a mandatory health insurance bill.

But Roosevelt wanted to keep the subject of health insurance and therefore established an Interdepartmental Committee to Coordinate Health and Welfare Activities immediately following the passage of the Social Security Act and ordered his staff to keep the subject out there before the public. Over the next few years it was the subject of many books and extensive studies by the federal government, but no bill yet.

More to come!!

The Democrats’ single-payer trap and Why Not Obamacare?? Let’s Start the Discussion of Medicare!!

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Richard North Patterson’s latest article started off with the statement- back in 2017-Behold the Republican Party, Democrats — and be warned.

The GOP’s ongoing train wreck — the defeat of its malign health care “reform,” the fratricidal troglodyte Roy Moore, and Donald Trump’s serial idiocies — has heartened Democrats. But before commencing a happy dance, they should contemplate the mirror.

They will see the absence of a compelling message. The party desperately needs a broad and unifying economic agenda — which includes but transcends health care — to create more opportunity for more Americans.

Instead, emulating right-wing Republicans, too many on the left are demanding yet another litmus test of doctrinal purity: single-payer health care. Candidates who waver, they threaten, will face primary challenges.

As regarding politics and policy, this is gratuitously dictatorial — and dangerously dumb.

The principle at stake is universal health care. Single-payer is but one way of getting there — as shown by the disparate approaches of countries that embrace health care as a right.

Within the Democratic Party, the discussion of these choices has barely begun. Senator Bernie Sanders advocates “Medicare for all,” expanding the current program for seniors. This would come at considerable cost — Sanders includes a 7.5 percent payroll tax among his list of funding options; others foresee an overall federal tax increase of 25 percent. But the dramatically increased taxes and the spending required, proponents insist, would be offset by savings in premiums and out-of-pocket costs.

Skeptics worry. Some estimate that Sanders’s proposal would cost $1.4 trillion a year — a 35 percent increase in a 2018 budget that calls for $4 trillion overall. It is not hard to imagine this program gobbling up other programs important to Democrats, including infrastructure, environmental protection, affordable college, and retraining for those dislocated by economic change.

For these reasons, most countries aspiring to universal care have multi-payer systems, which incorporate some role for private insurance, including France, Germany, Switzerland, and the Netherlands. The government covers most, but not all, of health care expenditures. Even Medicare, the basis for Sanderscare, allows seniors to purchase supplemental insurance — a necessity for many.

In short, single-payer sounds simpler than it is. Yet to propitiate the Democratic left, 16 senators have signed on to Sanders’s proposal, including potential 2020 hopefuls Elizabeth Warren, Cory Booker, Kamala Harris, and Kirsten Gillibrand. Less enthused are Democratic senators facing competitive reelection battles in 2018: Only one, Tammy Baldwin of Wisconsin, has followed suit.

This is the harrowing landscape the “single-payer or death” Democrats would replicate. Like “repeal and replace,” sweeping but unexamined ideas are often fated to collapse. Sanderscare may never be more popular than now — and even now its broader appeal is dubious.

Democrats must remember how hard it was to pass Obamacare. In the real world, Medicare for all will not become law anytime soon. In the meanwhile, the way to appeal to moderates and disaffected Democrats is not by promising to raise their taxes, but by fixing Obamacare’s flaws.

To enact a broad progressive agenda, the party must speak to voters nationwide, drawing on both liberals and moderates. Thus candidates in Massachusetts or Montana must address the preferences of their community. Otherwise, Democrats will achieve nothing for those who need them most.

Primary fights to the death over single payer will accomplish nothing good — including for those who want to pass single-payer. Parties do not expand through purges.

Democrats should be clear. It is intolerable that our fellow citizens should die or suffer needlessly, or be decimated by financial and medical calamity. A compassionate and inclusive society must provide quality health care for all.

The question is how best to do this. The party should stimulate that debate — not end it.

Generous Joe: More “Free” Healthcare For Illegals Needed

Now, R. Cort Kirkwood notes that Presidential candidate Joe Biden wants American taxpayers to pay for illegal alien healthcare. Indeed, he doesn’t just want us to pay for their healthcare, he says we are obliged to pay for their healthcare.

That’s likely because Biden thinks illegals are American citizens and doesn’t much care how many are here as long as they vote the right way.

What Biden didn’t explain when he said we must pay for illegal-alien healthcare is how much such beneficence would cost.

Answer: A lot.

The Question, The Answer

Biden’s demand that we pay for illegal-alien healthcare answered a question earlier this week from a reporter who wanted to know whether the “undocumented” deserve a free ride.

The question was this: “Do you think that undocumented immigrants who are in this country and are law-abiding should be entitled to federal benefits like Medicare, Medicaid for example?”

Answered Biden, “Look, I think that anyone who is in a situation where they are in need of health care, regardless of whether they are documented or undocumented, we have an obligation to see that they are cared for. That’s why I think we need more clinics in this country.”

Biden forgot to put “free” before clinics, but anyway, the candidate then suggested that Americans who disagree likely have a nasty hang-up about the border-jumping illegals who lie with the facility of Pinocchio when they apply for “asylum.”

“A significant portion of undocumented folks in this country are there because they overstayed their visas,” he continued. “It’s not a lot of people breaking down gates coming across the border,” he falsely averred.

Then came the inevitable. “We” need to watch what we say about all those “undocumented folks.”

“The biggest thing we’ve got to do is tone down the rhetoric,” he continued, because that “creates fear and concern” and ends in describing “undocumented folks” in “graphic, unflattering terms.”

Biden thinks those “undocumented folks” are citizens, as Breitbart noted in its report on his generosity with other people’s money.

In 2014, Biden told the worthies of the Hispanic Chamber of Commerce that entering the country illegally isn’t a problem, and Teddy Roosevelt would agree.

“The 11 million people living in the shadows, I believe they’re already American citizens,” Biden said. “Teddy Roosevelt said it better, he said Americanism is not a question of birthplace or creed or a line of dissent. It’s a question of principles, idealism, and character.”

Illegals “are just waiting, waiting for a chance to be able to contribute fully. And by that standard, 11 million undocumented aliens are already American.”

Roosevelt also said that “the one absolutely certain way of bringing this nation to ruin, of preventing all possibility of its continuing to be a nation at all, would be to permit it to become a tangle of squabbling nationalities,” but that inconvenient truth aside, Biden likely doesn’t grasp just what his munificence — again, with our money — will cost.

The Cost of Illegal-Alien Healthcare

I mentioned the cost of healthcare for the illegal-alien population and  Biden is right that visa overstays are a big problem: 701,900 in 2018, the government reported. But at least those who overstay actually entered the country legally; border jumpers don’t.

But that’s beside the point.

The real problem is the cost of the healthcare, which Forbes magazine estimated to be $18.5 billion, $11.2 billion of it federal tax dollars.

In 2017, the Federation for American Immigration Reform reported a figure of $29.3 billion; $17.1 in federal tax dollars, and $12.2 billion in state tax dollars. More than $15 billion on that total was uncompensated medical care. The rest fell under Medicaid births, Medicaid fraud, Medicaid for illegal-alien children, and improper Medicaid payouts.

The bills for the more than half-million illegals who have crossed the border since the beginning of fiscal 2019 in October are already rolling in.

Speaking at a news conference in March, Brian Hastings, operations chief for Customs and Border Protection (CBP), said about 55 illegals per day need medical care, and that 31,000 illegals will need medical care this year, up from 12,000 last year. Since December 22, he said, sick illegals have forced agents to spend 57,000 hours at hospitals or medical facilities. Cost: $2.2 million in salaries. Between 25 percent and 40 percent of the border agency’s manpower goes to the care and maintenance of illegals, he said.

CBP spent $98 million on illegal-alien healthcare between 2014 and 2018.

Hastings spoke before more than 200,000 illegals crossed the border in March and April.

NYC Promises ‘Guaranteed’ Healthcare for All Residents

Program to bring insurance to 600,000 people, including some who are undocumented

As the Mayor of New York City considers whether he wants to run for President and join the huge group of 21 candidates Joyce Frieden noted that the city of New York is launching a program to guarantee that every resident has health insurance, as well as timely access to physicians and health services, Mayor Bill de Blasio announced Tuesday.

“No one should have to live in fear; no one should have to go without the healthcare they need,” de Blasio said at a press conference at Lincoln Hospital in the Bronx. “In this city, we’re going to make that a reality. From this moment on in New York City, everyone is guaranteed the right to healthcare — everyone. We are saying the word ‘guarantee’ because we can make it happen.”

The program, which will cost $100 million annually, involves several parts. First, officials will work to increase enrollment in MetroPlus, which is New York’s public health insurance option. According to a press release from the mayor’s office, “MetroPlus provides free or affordable health insurance that connects insurance-eligible New Yorkers to a network of providers that includes NYC Health + Hospitals’ 11 hospitals and 70 clinics. MetroPlus serves as an affordable, quality option for people on Medicaid, Medicare, and those purchasing insurance on the exchange.”

The mayor’s office also said the new effort “will improve the quality of the MetroPlus customer experience through improved access to clinical care, mental health services, and wellness rewards for healthy behavior.”

For the estimated 600,000 city residents who don’t currently have health insurance — because they can’t afford what is on the Affordable Care Act health insurance exchange; because they’re young and healthy and choose not to pay for insurance, or because they are undocumented — the city will provide a plan that will connect them to reliable care at a sliding-scale fee. “NYC Care will provide a primary care doctor and will provide access to specialty care, prescription drugs, mental health services, hospitalization, and more,” the press release noted.

NYC Care will launch in summer 2019 and will roll out gradually in different parts of the city, starting in the Bronx, according to the release. It will be fully available to all New Yorkers across the city’s five boroughs in 2021.

Notably, the press release lacked many details on how the city will fund the plan and how much enrollees would have to pay. It also remained unclear how the city will persuade the “young invincibles” — those who can afford insurance but believe they don’t need it — to join up. Nor was arithmetic presented to document how much the city would save on city-paid emergency and hospital care by making preventive care more accessible. At the press conference, officials mostly deflected questions seeking details, focusing instead on the plan’s goals and anticipated benefits.

“Every New Yorker will have a card with [the name of] a… primary care doctor they can turn to that’s their doctor, with specialty services that make a difference, whether it’s ob/gyn care, mental health care, pediatric care — you name it, the things that people need will be available to them,” said de Blasio. “This is going to be a difference-maker in their lives. Get the healthcare you need when you need it.” And because more people will get preventive care, the city might actually save money, he added. “You won’t end up in a hospital bed if you actually get the care you need when the disease starts.”

People respond differently when they know something is guaranteed, he continued. “We know that if people don’t know they have a right to something, they’re going to think it’s not for them,” de Blasio said. “You know how many people every day know they’re sick [but can’t afford care] so they just go off to work and they get sicker?… They end up in the [emergency department] and it could have been prevented easily if they knew where to turn.”

As to why undocumented residents were included in the program, “I’m here to tell you everyone needs coverage, everyone needs a place to turn,” said de Blasio. “Some folks are our neighbors who happen to be undocumented. What do they all have in common? They need healthcare.”

Just having the insurance isn’t enough, said Herminia Palacio, MD, MPH, deputy mayor for health and human services. “It’s knowing where you can go for care and feeling welcome when you go for care… It’s being treated in a language you can understand by people who actually care about your health and well-being.”

De Blasio’s wife, Chirlane McCray, who started a mental health program, ThriveNYC, for city residents, praised NYC Care for increasing access to mental health services. “For 600,000 New Yorkers without any kind of insurance, mental healthcare remains out of reach [but this changes that],” she said. “When New Yorkers enroll in NYC Care they’ll be set up with a primary care doctor who can refer them [to mental health and substance abuse services], and psychiatric therapy sessions are also included.”

“The umbrella concept is crucial here,” said de Blasio. “If John or Jane Doe is sick, now they know exactly where to go. They have a name, an address… We want it to be seamless; if you have questions, here’s where to call.”

Help will be available at all hours, said Palacio. “Let’s say they’re having an after-hours issue and need understanding about where to get a prescription filled. They can call this number and get real-time help about what pharmacy would be open,” or find out which urgent care center can see them for a sore throat.

Mitchell Katz, MD, president, and CEO of NYC Health and Hospitals, the city’s public healthcare network, noted that prescription drugs are one thing most people are worried about being able to afford, but “under this program, pharmaceutical costs are covered.”

Katz noted that NYC Care is a more encompassing program than the one developed in San Francisco, where he used to work. For example, “here, psychotherapy is a covered benefit; that’s not true in San Francisco… and the current program [there] has an enrollment of about 20,000 people; that’s a New York City block. In terms of scale, this is just a much broader scale.”

In addition, the San Francisco program required employers to pay for some of it, while New York City found a way around that, de Blasio pointed out. The mayor promised that no tax increases are needed to fund the program; the $100 million will come from the city’s existing budget, currently about $90 billion.

Now on to Medicare for All as we look at the history of Medicare. I am so interested in the concept of Medicare for All as I look at my bill from my ophthalmologist, which did not cover any of my emergency visits for a partial loss of my right eye. Also, my follow-up appointment was only partially covered; they only covered $5 of my visit. Wonderful Medicare, right?

The invoice was followed this weekend with an Email from Medicare wishing me a Happy Birthday and notifying me of the preventive services followed with a table outlining the eligibility dates. And the dates are not what my physicians are recommending, so you see there are limitations regarding coverage and if and when we as patients can have the services.

Medicare as a program has gone through years of discussion, just like the Europeans, Germany to start, organized healthcare started with labor. In the book American Health Care edited by Roger D. Feldman, the German policy started with factory and mine workers and when Otto von Bismark in 1883, the then Chancellor of newly united Germany successfully gained passage of a compulsory health insurance bill covering all the factory and mine workers. A number of other series of reform measures were crafted including accident insurance, disability insurance, etc. The original act was later modified to include other workers including workers engaged in transportation, and commerce and was later extended to almost all employees. So, why did it take so long for we Americans form healthcare policies for our workers?

Just like in Germany and then Britain, the discussion of healthcare reform began with labor and, of course, was battered about in the political arena. In 1911, after the passage of the National Health Act in Britain, Louis Brandeis, who was later to be appointed to the Supreme Court, urged the National Conference on Charities and Corrections to support a national program of mandatory medical insurance. The system of compulsory health insurance soon became the subject of American politics starting with Theodore Roosevelt, head of the Progressive or Bull Moose. H delivered his tedious speech, “Confession of Faith”, calling for a national compulsory healthcare system for industrial workers.  The group that influenced Roosevelt was a group of progressive economists from the University of Wisconsin, who were protégés of the labor economist John R. Commons, a professor at the university.

Commons an advocate of the welfare state, in 1906, together with other Progressive social scientists at Wisconsin, founded the American Association for Labor Legislation (AALL) to labor for reform on both the federal and state level. Roosevelt and other members of the Progressive Party pushed for compulsory health insurance, which they were convinced would be endorsed by working-class Americans after the passage of the British national program.

The AALL organization expanded membership and was responsible for protective labor legislation and social issues. One of the early presidents of the organization was William Willoughby, who had authored a comprehensive report on European government health insurance scheme in 1898.

The AALL next turned its attention to the question of a mandatory health insurance bill and sought the support of the American Medical Association. The AMA  was thought to support this mandatory health insurance bill if it could be shown that the introduction of a mandatory health insurance program would in fact profit physicians. This is where things go complicated and which eventually doomed the support of the AMA and all physicians as a universal health insurance plan failed in Congress. Why? Because the model bill developed by the AALL had one serious flaw. It did not clearly stipulate whether physicians enrolled in the plan would be paid in the basis of capitation fee or fee-for-service, nor did it ensure that practitioners be represented on administrative boards.

I discuss more on the influence of the AALL in health care reform and what happened through the next number of Presidents until Kennedy.

More to come! Happy Mother’s Day to all the great Mothers out there and your wonderful influence on all your families with their guidance and love.

 

 

bernie168

Peter Sullivan reported that Congressional Republicans don’t want to talk about attacks on ObamaCare. But President Trump isn’t making that easy.

The Trump administration on Wednesday filed its official legal argument calling for the entirety of the Affordable Care Act to be struck down, once again thrusting the issue back in the spotlight at a time when GOP lawmakers are trying to turn the page.

Republicans would much rather focus on criticizing the “Medicare for All” proposal backed by more and more Democrats, something they see as a winning line of attack compared to reigniting an ObamaCare debate that contributed to the GOP losing its majority in the House last year.

Trump, though, is not playing along with that strategy; instead, he is keeping up his attacks on ObamaCare in court and in his speeches.

Asked if he wished the Trump administration was not arguing so forcefully against the 2010 health care law in court, Sen. John Thune(S.D.), the No. 2 Senate Republican, separated congressional Republicans from the White House.

“They’re going to do what they’re going to do,” Thune said. “What we have to worry about is what our members are working on, what we’re trying to do and how we’re communicating that to the American people.”

Sen. Chuck Grassley (R-Iowa), chairman of the Senate Finance Committee, declined to say he supported the administration’s move.

“The president can message whatever he wants to message, and there’s no control I have over what he can message,” Grassley said.

With all the talk of collusion, lies, threats of impeachment our Congress is really doing nothing for real healthcare improvement. And Republicans have been beating the drum almost daily to get across their main health care message: that Medicare for All would take away people’s private health insurance and come with an enormous price tag.

Republicans this week seized on a new report from the nonpartisan Congressional Budget Office examining projected costs associated with Medicare for All. While the report did not put a specific price tag on the proposal, it said government spending on health care would “increase substantially.”

Previous studies have put the cost to the government around $32 trillion over 10 years. I will try to break down the numbers.

But one side effect of the GOP’s attacks on Medicare for All is that it comes close to defending the status quo, which includes ObamaCare.

This is the problem with the GOP, they have no real plan for healthcare and although that they have had many months for the solution-they have none.

Rep. Tom Cole (R-Okla.) asked at a hearing this week on Medicare for All why lawmakers don’t just focus on bipartisan fixes to ObamaCare instead of pursuing the sweeping new system that’s championed by progressives like 2020 presidential candidate Sen. Bernie Sanders (I-Vt.).

“We have a chance, I think, to make some fixes that we probably all agree on,” Cole said.

Over the past few months, though, GOP lawmakers had been mostly silent on ObamaCare, a law they aggressively attacked for eight years.

The Affordable Care Act’s popularity has been rising in recent years, with a Kaiser Family Foundation poll in April finding that 50 percent of adults have a favorable view of the law, compared to 38 percent with an unfavorable one.

Most Democrats last year campaigned on maintaining the law’s popular protections for people with pre-existing conditions.

“The last thing Senate Republicans want to be doing is participating in an exercise that would potentially remove coverage from people with pre-existing conditions that they already have,” said a Senate GOP strategist. “Candidates in tough races will be emphasizing how to improve on what currently exists.”

Senate Majority Leader Mitch McConnell (R-Ky.) last month said the GOP health care message is “preserving what works and fixing what doesn’t,” a very different slogan than the party’s long-time mantra of “repeal and replace.”

Trump, though, is on the attack against ObamaCare. In a speech last week, he touted the 2017 repeal of the law’s mandate to have coverage before adding, “Now we’re going for the rest.”

His administration is also supporting the lawsuit brought by a coalition of GOP-led states calling for overturning the law. That case, which legal experts in both parties dismiss as unlikely to succeed, is now making its way through the 5th Circuit Court of Appeals.

Vulnerable Republican lawmakers are not eager to talk about the administration’s efforts on that front.

Sen. Cory Gardner (R-Colo.), perhaps the most vulnerable GOP senator up for reelection next year, said Thursday that he had not seen the administration’s legal filing, declining to comment on it and on his views on the lawsuit. His office did not respond to a follow-up inquiry.

Rep. John Katko (R-N.Y.), a moderate who is facing a potentially competitive race next year, distanced himself from the lawsuit.

“I don’t agree with anything being taken out without a replacement ready,” he said.

Sen. Shelley Moore Capito (R-W.Va.) noted the failure of the GOP’s repeal attempt in 2017.

“Obviously the repeal-and-replace discussion wasn’t successful, so let’s put that behind us and let’s make this one work,” she said.

Thune, though, suggested that if Republicans were in control of both chambers again, they would likely attempt another repeal-and-replace measure.

“Obviously, if and when we have the votes, we’d like to take a different direction, one that would create more competition and more choices and lower costs,” Thune said.

So, the Real Question is Would ‘Medicare for All’ Save

Josh Katz, Kevin Quealy, and Margot Sanger-Katz last month reviewed U.S. Health Care Expenditures in 2019

Total cost under current law out of pocket$1.00Private health insurance$1.00Other health spending$514 billion other health insurance$149 billionMedicaid$1.00Medicare for All$3.87 trillion

How much would a “Medicare for all” plan, like the kind being introduced by Senator Bernie Sanders on Wednesday, change health spending in the United States?

Some advocates have said costs would actually be lower because of gains in efficiency and scale, while critics have predicted huge increases.

We asked a handful of economists and think tanks with a range of perspectives to estimate total American health care expenditures in 2019 under such a plan. The chart at the top of this page shows the estimates, both in composition and in total cost.

In all of these estimates, patients and private insurers would spend far less, and the federal government would pay far more. But the overall changes are also important, and they’re larger than they may look. Even the difference between the most expensive estimate and the second-most expensive estimate was larger than the budget of most federal agencies.

Annotation 2019-04-13 234119.Estimates of cost of medicare for all.a

The big differences in the estimates of experts reflect the challenge of forecasting a change of this magnitude; it would be the largest domestic policy change in a generation.

The proposals themselves are vague on crucial points. More broadly, any Medicare for all system would be influenced by the decisions and actions of parties concerned — patients, health care providers, and political actors — in complex, hard-to-predict ways. But seeing the range of responses, and the things that all the experts agree on can give us some ideas about what Medicare for all could mean for the country’s budget and economy.

These estimates come from:

Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Bernie Sanders presidential campaign in 2016.

Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security.

Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals.

Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006.

Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes.

Right now, individuals and employers pay insurance premiums; people pay cash co-payments for drugs, and state governments pay a share of Medicaid costs. In a Sanders-style system or one recently introduced by Representative Pramila Jayapal and the Congressional Progressive Caucus, nearly all of that would be replaced by federal spending. That’s why some experts describe such a system as single-payer. (Other Democrats who are supporting coverage expansion through Medicare have offered more modest proposals that would preserve some out-of-pocket spending and a role for private insurance.)

The economists made their calculations using different assumptions and methods, and you can read more about those methods at the bottom of this article.

These two estimates, for example, from the Mercatus Center and the Urban Institute, differ by about $730 billion per year, roughly 3 percent of G.D.P. The two groups don’t often agree on public policy — Mercatus tends to be more right-leaning and Urban more left-leaning.

Annotation 2019-04-13 234303.estimates for medicare for all.b

The biggest difference between the Mercatus estimate and the Urban one is related to how much the new system would pay doctors, hospitals and other medical providers for health services. Mr. Friedman’s estimate, the least expensive of the group, assumed that the government could achieve the largest cost savings on both prescription drugs and administrative spending.

How much would doctors and hospitals and other providers be paid?

Pay too little, and you risk hospital closings and unhappy health care providers. Pay too much, and the system will become far more expensive. Small differences add up.

The estimated increase in Medicare payment rates paid to medical providers

FRIEDMAN BLAHOUS THORPE URBAN RAND
6% 0% 5% 7% 9%

In our current system, doctors, hospitals and other health care providers are paid by a number of insurers, and those insurers all pay them slightly different prices. In general, private insurance pays medical providers more than Medicare does. Under a Medicare for all system, Medicare would pick up all the bills. Paying the same prices that Medicare pays now would mean an effective pay cut for medical providers who currently see a lot of patients with private insurance.

For a Medicare for all system to save money, it needs to reduce the health care industry’s income somewhat. But if rates are too low, hospitals already facing financial difficulties could be put out of business.

Neither Mr. Sanders’s legislation nor the Jayapal House bill specifies what the Medicare for all system would pay, but they say that Medicare would establish budgets and payment rates. So our estimators offered their best guess of what they thought such a plan might do.

Mr. Thorpe said he picked a number higher than current Medicare prices for hospitals because he thought anything lower would be unsustainable. Mr. Blahous said he constructed his starting estimate at precisely Medicare rates, though he thought the real number would most likely be higher. He also reran his calculations with a more generous assumption: At 111 percent of Medicare, around the average amount all health insurers pay medical providers now, the total shot up by hundreds of billions of dollars, about an additional 1.5 percent of G.D.P.

How much lower would prescription costs be?

By negotiating directly on behalf of all Americans, instead of having individual insurance companies and plans bargain separately, the government should be able to pay lower drug prices.

The estimated reduction in drug spending

FRIEDMAN BLAHOUS THORPE URBAN RAND
31% 12% 4% 20% 11%

Patients in the United States pay the highest prices in the world for prescription drugs. That’s partly a result of a fractured system in which different payers negotiate separately for drug benefits. But it also reflects national preferences: An effective negotiator needs to be able to say no, and American patients tend to want access to the widest array of cutting-edge drugs, even if it means paying more.

A Medicare for all system would have more leverage with the drug industry because it could bargain for the whole country’s drug supply at once. But politics would still be a constraint. A system willing to pay for fewer drugs could probably get bigger discounts than one that wanted to preserve the current set of choices. That would mean, though, that some patients would be denied the medications they want.

All of our economists thought a Medicare for all system could negotiate lower prices than the current ones. But they differed in their assessments of how cutthroat a negotiator Medicare would be. Mr. Friedman thought Medicare for all could reduce drug spending by nearly a third. The Urban team said the savings would be at least 20 percent. The other researchers imagined more modest reductions.

How much more would people use the health care system?

By expanding coverage to the uninsured, adding new benefits and wiping out cost sharing, Medicare for all would encourage more Americans to seek health care services.

The estimated increase in the use of health care

FRIEDMAN BLAHOUS THORPE URBAN RAND
7% 11% 15% 8%

Medicare for all would give insurance to around 28 million Americans who don’t have it now. And evidence shows that people use more health services when they’re insured. That change alone would increase the bill for the program.

Other changes to Medicare for all would also tend to increase health care spending. Some proposals would eliminate nearly all co-payments and deductibles. Evidence shows that people tend to go to the doctor more when there’s no such cost sharing. The proposed plans would also add medical benefits not typically covered by health insurance, such as dental care, hearing aids, and optometry services, which would increase their use.

The economists differ somewhat in how much they think people would increase their use of medical services. (Because of the way the Urban Institute team’s estimate was calculated, it couldn’t easily provide a number for this question.

What would Medicare for all cost to run?

Right now, the health care system is complicated, with lots of different payers and ways to negotiate prices and bill for services. A single payment system could save some money by simplifying all that.

Estimated administrative costs as a share of all spending

FRIEDMAN BLAHOUS THORPE URBAN RAND
2% 6% 6% 5%

The complexity of the American system means that administrative costs can often be high. Insurance companies spend on negotiations, claims review, marketing and sometimes shareholder returns. One key possible advantage of a Medicare for all system would be to strip away some of those overhead costs.

But estimating possible savings in management and administration is not easy. Medicare currently has a much lower administrative cost share than other forms of insurance, but it also covers sicker people, distorting such comparisons. Certain administrative functions, like fraud detection, can have a substantial return on investment.

The economists all said administrative costs would be lower under Medicare for all, but they differed on how much. Those differences amount to percentage points on top of the differing estimates of medical spending. On this question, there was rough agreement among our estimators that administrative costs would be no higher than 6 percent of medical costs, a number similar to the administrative costs that large employers spend on their health plans. Mr. Blahous said a 6 percent estimate would probably apply to populations currently covered under private insurance but did not calculate an overall rate.

But what will it cost me?

All of these estimates looked at the potential health care bill under a Sanders-style Medicare for all plan. In some estimates, the country would not pay more for health care, but there would still be a drastic shift in who is doing the paying. Individuals and their employers now pay nearly half of the total cost of medical care, but that percentage would fall close to zero, and the percentage paid by the federal government would rise to compensate. Even under Mr. Blahous’s lower estimate, which assumes a reduction in overall health care spending, federal spending on health care would still increase by 10 percent of G.D.P., or more than triple what the government spends on the military.

How that transfer takes place is one of the least well-explained parts of the reform proposals. Taxation is the most obvious way to collect that extra revenue, but so far none of the current Medicare for all proposals have included a detailed tax plan. Even if total medical spending stayed flat overall, some taxpayers could come out ahead and pay less; others could find themselves paying more.

Raising revenue would require broad tax increases that are likely to be partly borne by the middle class, potentially impeding passage. Advocates, including Mr. Sanders, tend to favor funding the program with payroll taxes.

For some people, any increase in federal taxes might be more than offset by reductions in their spending on premiums, co-payments, deductibles, and state taxes. There is evidence to suggest that premium savings by employers would also be returned to workers in the form of higher salaries. But, depending on the details, other groups could end up paying more in tax increases than they save in those reductions.

After Mr. Sanders’s presidential campaign released a tax proposal in 2016, the Urban Institute tried to calculate the effects on different groups. But it found that the proposed taxes would pay for only about half of the increased federal bill. That means that a real financing proposal would probably need to raise a lot more in taxes. How those are spread across the population would change who would be better or worse off under Medicare for all.

About the estimates

Our economists differed somewhat in their estimation methods. They also examined a couple of different Medicare for all proposals, though all the plans had the same major features.

Gerald Friedman calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2018 paper with his analysis of several different variations on Medicare for all is available.

Kenneth E. Thorpe calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. A 2016 paper with more of his findings on Mr. Sanders’s presidential campaign proposal is available.

The Urban Institute built its estimates using a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The model does not consider the effects of policy changes on military and veterans’ health care or the Indian Health Service, so its totals assumed those programs would not change. It also measures limits on the availability of doctors and hospitals using evidence from the Medicaid program. The team at Urban that prepared the calculations includes John Holahan, Lisa Clemans-Cope, Matthew Buettgens, Melissa Favreault, Linda J. Blumberg and Siyabonga Ndwandwe. Its detailed report on Mr. Sanders’s presidential campaign proposal from 2016 is available.

Charles Blahous calculated the cost of Medicare for all by making adjustments to current health care spending using assumptions he derived from the research literature. His measurements didn’t capture the behavior of individual Americans, but estimated broader changes as groups of people gained access to different insurance, and as medical providers earned a different mix of payments. His calculations were made based on Mr. Sanders’s 2017 Medicare for All Act, which indicated that states would continue to pay a share of long-term care costs. A 2018 paper with more of his findings is available and includes both sets of estimates for Medicare provider payments.

The RAND Corporation built its estimates by making adjustments to previous single-payer analyses. The original estimates used a microsimulation model, which estimates how individuals with different incomes and health care needs would respond to changes in health insurance. The RAND model, which it uses to estimate the effects of various health policy changes, is called RAND COMPARE. Calculations were made assuming a Medicare for all plan that offers coverage with no cost-sharing and long-term care benefits. The RAND team that prepared the estimate includes Christine Eibner and Jodi Liu. A copy of the report is available; Ms. Liu’s 2016 study of how different.

Maybe we should spend some time reviewing the history of Medicare to get a better idea of the system. I’ll do that over the next few weeks.