Category Archives: Undocumented immigrants

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.

Decline in measles vaccination is causing a preventable global resurgence of the disease

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What a horrible week with the burning or Notre Dame, the Democrats all piling on to tear apart the Mueller report and threaten to impeach the President and the tragedy in Sri Lanka. But the thing that really annoyed me is the increasing number of patients with measles, now over 500 in this country due to non vaccinated children, etc.. These anti-vaxers are spoiled and selfish. But I bet that when their children get really sick they will demand the best care from any and all hospitals, physicians and nurses out there or threaten to sue them. So, the Single-payer healthcare discussion will have to wait a week!

The NIH/National Institute of Allergy and Infectious Diseases pointed out that in 2000, measles was declared to be eliminated in the United States when no sustained transmission of the virus was seen in this country for more than 12 months. Yes, you read that right; it was declared to have been eliminated. What happened then?

Today, however, the United States and many other countries that had also eliminated the disease are experiencing concerning outbreaks of measles because of declines in measles vaccine coverage. Without renewed focus on measles vaccination efforts, the disease may rebound in full force, according to a new commentary in the New England Journal of Medicine by infectious diseases experts at the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, and the Penn State University College of Medicine’s Milton S. Hershey Medical Center.

Measles is an extremely contagious illness transmitted through respiratory droplets and aerosolized particles that can remain in the air for up to two hours. Most often seen in young children, the disease is characterized by fever, malaise, nasal congestion, conjunctivitis, cough, and a red, splotchy rash. Most people with measles recover without complications within a week. However, for infants, people with immune deficiencies, and other vulnerable populations, the consequences of measles infection can be severe. Rare complications can occur, including pneumonia, encephalitis, other secondary infections, blindness, and even death. Before the measles vaccine was developed, the disease killed between two and three million people annually worldwide. Today, measles still causes more than 100,000 deaths globally each year.

Measles can be prevented with a vaccine that is both highly effective and safe. Each complication and death related to measles is a “preventable tragedy that could have been avoided through vaccination,” the authors write. Some people are reluctant to vaccinate their children based on widespread misinformation about the vaccine. For example, they may fear that the vaccine raises their child’s risk of autism, a falsehood based on a debunked and fraudulent claim. A very small number of people have valid medical contraindications to the measles vaccine, such as certain immunodeficiencies, but almost everyone can be safely vaccinated.

When levels of vaccine coverage fall, the weakened umbrella of protection provided by herd immunity—indirect protection that results when a sufficiently high percentage of the community is immune to the disease—places unvaccinated young children and immunocompromised people at greater risk. This can have disastrous consequences with measles. The authors describe a case in which a single child with measles infected 23 other children in a pediatric oncology clinic, with a fatality rate of 21 percent.

Now, look at the situation in New York City.

If vaccination rates continue to decline, measles outbreaks may become even more frequent, a prospect the authors describe as “alarming.” This is particularly confounding, they note since measles is one of the most easily prevented contagious illnesses. In fact, it is possible to eliminate and even eradicate the disease. However, they say, achieving this goal will require collective action on the part of parents and healthcare practitioners alike.

New York Declares Measles Emergency, Requiring Vaccinations in Parts of Brooklyn

New York City on Tuesday declared a health emergency following a measles outbreak in the Orthodox Jewish community in Brooklyn. Demetrius Freeman for The New York Times reported.

Tyler Pager and Jeffery Mays reported that for months, New York City officials have been fighting a measles outbreak in ultra-Orthodox Jewish communities in Brooklyn, knowing that the solution — the measles vaccine — was not reaching its target audience.

They tried education and outreach, working with rabbis and distributing thousands of fliers to encourage parents to vaccinate their children. They also tried harsher measures, like a ban on unvaccinated students from going to school.

But with measles cases still on the rise and an anti-vaccination movement spreading, city health officials on Tuesday took a more drastic step to stem one of the largest measles outbreaks in decades.

Mayor Bill de Blasio declared a public health emergency that would require unvaccinated individuals living in Williamsburg, Brooklyn, to receive the measles vaccine. The mayor said the city would issue violations and possible fines of $1,000 for those who did not comply.

“This is the epicenter of a measles outbreak that is very, very troubling and must be dealt with immediately,” Mr. de Blasio said at a news conference in Williamsburg, adding: “The measles vaccine works. It is safe, it is effective, it is time-tested.”

The measure follows a spike in measles infections in New York City, where there have been 285 confirmed cases since the outbreak began in the fall; 21 of those cases led to hospitalizations, including five admissions to the intensive care unit.

City officials conceded that the earlier order in December, which banned unvaccinated students from attending schools in certain sections of Brooklyn, was not effective. Mr. de Blasio said on Tuesday that the city would fine or even temporarily shut down yeshivas that did not abide by the measure.

“There has been some real progress in addressing the issue, but it’s just not working fast enough and it was time to take a more muscular approach,” Mr. de Blasio said.

To enforce the order, health officials said they did not intend to perform random spot checks on students; instead, as new measles cases arose, officials would check the vaccination records of any individuals who were in contact with those infected.

“The point here is not to fine people but to make it easier for them to get vaccinated,” Dr. Oxiris Barbot, the city’s health commissioner, said at the news conference.

If someone is fined but still refuses to be vaccinated, Dr. Barbot said that would be handled on a “case-by-case basis, and we’ll have to confer with our legal counsel.”

Across the country, there have been 465 measles cases since the start of 2019, with 78 new cases in the last week alone, the Centers for Disease Control and Prevention said on Monday.

In 2018, New York and New Jersey accounted for more than half of the measles cases in the country, and the continuing outbreak has led to unusual measures.

In Rockland County, N.Y., a northern suburb of New York City, county health officials last month barred unvaccinated children from public places for 30 days. Last week, however, a judge ruled against the order, temporarily halting it.

“This is the epicenter of a measles outbreak that is very, very troubling and must be dealt with immediately,” Mayor Bill de Blasio said on Tuesday.

“This is the epicenter of a measles outbreak that is very, very troubling and must be dealt with immediately,” Mayor Bill de Blasio said on Tuesday.CreditJohn Taggart for The New York Times

Despite the legal challenge to Rockland County’s efforts, Mr. de Blasio said the city had consulted its lawyers and felt confident it was within its power to mandate vaccinations.

“We are absolutely certain we have the power to do this,” Mr. de Blasio said. “This is a public health emergency.”

[In Rockland County, an outbreak spread fear in an ultra-Orthodox community.]

Dr. Paul Offit, a professor of pediatric infectious diseases at Children’s Hospital of Philadelphia, said there was the precedent for Mr. de Blasio’s actions, pointing to a massive measles outbreak in Philadelphia in 1991. During that outbreak, officials in that city went even further, getting a court order to force parents to vaccinate their children.

“I think he’s doing the right thing,” Dr. Offit said about Mr. de Blasio. “He’s trying to protect the children and the people of the city.”

He added: “I don’t think it’s your unalienable right as a United States citizen to allow your child to catch and transmit a potentially fatal infection.”

Nonetheless, the resistance to the measles vaccine remains among some ultra-Orthodox in Brooklyn.

Gary Schlesinger, the chief executive of Parcare, a health and medical center with locations in Williamsburg and Borough Park, called the public health emergency a necessary “step in the right direction.”

“Any mother that comes in and says that they don’t want to vaccinate, our providers will tell them please go find another health center,” Mr. Schlesinger said.

He said he often reminded Orthodox parents that there was no religious objection to getting vaccinated. “Any prominent rabbi will say that you should vaccinate,” he said.

Just outside the public library where Mr. de Blasio held his news conference, some Hasidic mothers raised concerns about the emergency declaration.

“I don’t think it’s up to the city to mandate anything. We all have constitutional rights,” said a woman who only identified herself by Gitty. She refused to give her last name for fear of being harassed for her rejection of vaccinations.

She said she had five children and that none had been or would be vaccinated, an action she called “a medical procedure by force.”

“We are marginalized,” she said. “Every minority that has a different opinion is marginalized.”

In nearby South Williamsburg, reaction to the emergency order was mixed. Some agreed with the need for vaccinations, but did not believe the law should require them; others agreed with the mayor.

“He’s right,” said Leo Yesfriedman, a 33-year-old father of four who said he had his family vaccinated.

He said he had followed news of the measles outbreak. Of people in his community opposed to vaccinations, he said, “It’s a very, very little percentage of crazy people.”

Measles Outbreak: Yeshiva’s Preschool Program Is Closed by New York City Health Officials

The program is the first one to be closed as part of the city’s escalating effort to stem the country’s largest measles outbreak in decades.

Children leaving a yeshiva’s preschool program in Williamsburg on Monday. It is the first to be closed by New York City officials for violating a Health Department order.

The New York Times John Taggart reported that New York City closed a preschool program at a yeshiva in Brooklyn on Monday for violating a Health Department order that required it to provide medical and attendance records amid a measles outbreak.

The preschool at United Talmudical Academy, which serves 250 students between the ages of 3 and 5 in the Williamsburg area, is the first program to be closed by the city, as it escalates efforts to stem the country’s largest measles outbreak in decades.

New York City has confirmed 329 measles cases since the outbreak began in the fall, and the cases have largely been confined within the ultra-Orthodox Jewish community. The outbreak began after unvaccinated individuals returned from celebrating Sukkot, a Jewish harvest festival, in Israel.

The closing of the preschool comes as tensions have risen in the ultra-Orthodox community over increased scrutiny and fears of an anti-Semitic backlash. On the one hand, most in the ultra-Orthodox community are vaccinated, and the vast majority of prominent rabbis have urged people to vaccinate their children. However, the city’s response to the outbreak has caused vaccine skeptics to double down on their opposition to immunization. The anti-vaccination movement’s well-coordinated and sophisticated messaging campaign, highlighted by magazines, hotlines, and conference calls, has convinced some parents that vaccines are dangerous and that diseases, like measles, are not.

In December, the city issued exclusion orders, barring unvaccinated students from attending school in certain neighborhoods. The city issued violations to 23 yeshivas and day care centers for breaking that order. But, last month, the city said it would no longer issue violations; rather, it would immediately close yeshivas.

“The challenge has been with this particular school that they have been unable and/or unwilling to provide documentation as required when we visit,” Dr. Oxiris Barbot, the city’s health commissioner, said at a news conference on Monday. “So we have visited on a number of occasions and offered support, but in spite of all of that it’s been to no avail.”

The Health Department said the preschool would not be allowed to reopen until its staff had “submitted a corrective action plan approved by the department.”

At the news conference, health officials said two students associated with the school had contracted measles, though they did not know for sure whether the students had been infected with the virus at the school or elsewhere.

Last week, Mayor Bill de Blasio declared a public health emergency, requiring all individuals living in certain ZIP codes of Brooklyn to be vaccinated against measles or face a $1,000 fine. On Monday, a group of parents filed a lawsuit against the order, arguing it was unjustified because of “insufficient evidence of a measles outbreak or dangerous epidemic.”

“Our attempts at education and persuasion have failed to stop the spread of measles,” Nick Paolucci, a spokesman for the city’s Law Department, said in a statement. “We had to take this additional action to fulfill our obligation to ensure that individuals do not continue to put the health of others at risk. We are confident that the city’s order is within the health commissioner’s authority to address the very serious danger presented by this measles outbreak.”

A judge declined to issue an emergency injunction against the city on Monday, and the parties will appear in court on Thursday.

There have been no deaths associated with this outbreak, but 25 individuals have been hospitalized. Two patients remain in the intensive care unit.

90 New Cases of Measles Reported in the U.S. as Outbreak Continues Record PaceApril 15, 2019

“This outbreak will continue to worsen, and the case count will grow if child care programs and schools do not follow our direction,” Dr. Barbot said in a statement. “It’s crucial in this outbreak that child care programs and schools maintain up-to-date and accurate immunization and attendance records. It’s the only way we can make sure schools are properly keeping unvaccinated students and staff out of child care centers to hasten the end of this outbreak.”

A teacher at United Talmudical Academy, who declined to give his name, said that all students who were not vaccinated were sent home weeks ago.

“It was a few kids who didn’t take the shots,” he said, as he exited the building. “They’re not coming back.”

A 68-year-old community member, who declined to give his name, said he did not think the school should be closed down.

“The parents should be held accountable,” he said.

He added that the community will be “very angry” that the school was shut down.

Measles outbreaks have also been reported in Rockland and Westchester Counties, suburbs of New York. Since January, 555 cases of measles have been reported in the United States, the Centers for Disease Control and Prevention said on Monday, noting the outbreak is on pace to be the largest since the country declared measles eradicated in 2000.

Exemptions Surge As Parents And Doctors Do ‘Hail Mary’ Around Vaccine Laws

Barbara Feder Ostrov noted that at two public charter schools in the Sonoma wine country town of Sebastopol, more than half the kindergartners received medical exemptions from state-required vaccines last school year. The cities of Berkeley, Santa Cruz, Nevada City, Arcata, and Sausalito all had schools in which more than 30% of the kindergartners had been granted such medical exemptions.

Nearly three years ago, with infectious disease rates ticking up, California enacted a fiercely contested law barring parents from citing personal or religious beliefs to avoid vaccinating their children. Children could be exempted only on medical grounds if the shots were harmful to health.

Yet today, many of the schools that had the highest rates of unvaccinated students before the new measure continue to hold that alarming distinction. That’s because parents have found end-runs around the new law requiring vaccinations. And they have done so, often, with the cooperation of doctors — some not even pediatricians. One prolific exemption provider is a psychiatrist who runs an anti-aging clinic.

Doctors in California have broad authority to grant medical exemptions to vaccination and to decide the grounds for doing so. Some are wielding that power liberally and sometimes for cash: signing dozens — even hundreds — of exemptions for children in far-off communities.

“It’s sort of the Hail Mary of the vaccine refusers who is trying to circumvent SB 277,” the California Senate bill signed into law by Gov. Jerry Brown in 2015, said Dr. Brian Prystowsky, a Santa Rosa pediatrician. “It’s really scary stuff. We have pockets in our community that is just waiting for measles to rip through their schools.”

The number of California children granted medical exemptions from vaccinations has tripled in the past two years.

Medical Exemptions On The Rise

The number of California children with medical vaccine exemptions has tripled in the two years since California enacted a 2016 law banning exemptions based on personal beliefs.

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Across the nation, 2019 is shaping up to be one of the worst years for U.S. measles cases in a quarter-century, with major outbreaks in New York, Texas, and Washington state, and new cases reported in 12 more states, including California. California’s experience underlines how hard it is to get parents to comply with vaccination laws meant to protect public safety when a small but adamant population of families and physicians seems determined to resist.

When Senate Bill 277 took effect in 2016, California became the third state, after Mississippi and West Virginia, to ban vaccine exemptions based on personal or religious beliefs for public and private school students. (The ban does not apply to students who are home-schooled.)

In the two subsequent years, SB 277 improved overall child vaccination rates: The percentage of fully vaccinated kindergartners rose from 92.9% in the 2015-16 school year to 95.1% in 2017-18.

But those gains stalled last year due to the dramatic rise in medical exemptions: More than 4,000 kindergartners received these exemptions in the 2017-18 school year. Though the number is still relatively small, many are concentrated in a handful of schools, leaving those classrooms extremely vulnerable to serious outbreaks.

Based on widely accepted federal guidelines, vaccine exemptions for medical reasons should be exceedingly rare. They’re typically reserved for children who are allergic to vaccine components, who have had a previous reaction to a vaccine, or whose immune systems are compromised, including kids being treated for cancer. Run-of-the-mill allergies and asthma aren’t reasons to delay or avoid vaccines, according to the U.S. Centers for Disease Control and Prevention. Neither is autism.

Before California’s immunization law took effect, just a fraction of 1% of the state’s schoolchildren had medical exemptions. By last school year, 105 schools, scattered across the state, reported that 10% or more of their kindergartners had been granted medical exemptions. In 31 of those schools, 20% or more of the kindergartners had medical exemptions.

Seesawing Exemptions

As of July 2016, California no longer allows parents to exempt their children from state-required vaccinations based on personal beliefs. Many of the same schools that once had the highest percentage of students with personal belief exemptions now lead the state in student medical exemptions.

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Credit: Harriet Blair Rowan/California Healthline

Source: California Department of Public Health Get the data created with Datawrapper

The spike in medical exemptions is taking place amid a politically tinged, often rancorous national conversation over vaccines and personal liberty as measles resurges in the U.S. and worldwide. At least 387 cases of measles had been reported nationwide through March 28, according to the CDC. In California, 16 cases had been reported, two of them requiring hospitalization.

The problem in California, state officials say, is how the immunization law was structured. It removed the ability of parents to cite “personal belief” as a reason for exempting their children from vaccine requirements in daycare and schools. A licensed physician who provides a written statement citing a medical condition that indicates immunization “is not considered safe” now must authorize exemptions.

But the law does not specify the conditions that qualify a student for a medical exemption, nor does it require physicians to follow federal guidelines.

The wording has led to a kind of gray market in which parents share names of “vaccine-friendly” doctors by word of mouth or in closed Facebook groups. And some of those doctors are granting children blanket exemptions — for all time and all vaccines — citing a range of conditions not supported by federal guidelines, such as a family history of eczema or arthritis.

Amid growing concerns about suspect exemptions, the California Department of Public Health recently launched a review of schools with “biologically unlikely” numbers of medical exemptions, said the agency’s director, Dr. Karen Smith. Doctors who have written questionable exemptions will be referred to the Medical Board of California for a possible investigation.

The medical board, which licenses doctors, has the authority to levy sanctions if physicians have not followed the standard medical practice in examining patients or documenting specific reasons for an exemption.

In recent years, however, the board has sanctioned only one doctor for inappropriately writing a medical vaccine exemption in a case that made headlines. Since 2013, the board has received 106 complaints about potentially improper vaccine exemptions, including nine so far this year, said spokesman Carlos Villatoro.

One pending case involves Dr. Ron Kennedy, who was trained as a psychiatrist and now runs an anti-aging clinic in Santa Rosa.

Medical board investigators took the unusual step of subpoenaing 12 school districts for student medical records after receiving complaints that Kennedy was writing inappropriate exemptions. They found that Kennedy had written at least 50 exemptions, using nearly identical form letters, for students in multiple communities, including Santa Rosa, Fremont, and Fort Bragg, saying that immunizations were “contraindicated” for a catchall list of conditions including lupus, learning disability, food allergies and “detoxification impairment.”

Dr. Dean Blumberg, chief of pediatric infectious diseases at UC Davis Children’s Hospital and the medical board’s expert witness, said that the exemptions issued by Kennedy appear to have been provided “without appropriate evaluation,” according to court documents.

Kennedy has refused to respond to the board’s subpoenas seeking the medical records of three of his patients, according to court documents. The board has yet to file a formal accusation against Kennedy, and he continues to practice.

Like Kennedy, many of the doctors granting unorthodox exemptions cite their belief in parental rights or reference concerns not supported by conventional medical science. Kennedy is suing the medical board and its parent agency, the California Department of Consumer Affairs, saying the state did not have the legal right to subpoena school districts for his patients’ medical records without first informing him so he could challenge the action in court. The case is ongoing.

Kennedy declined to comment to Kaiser Health News. “I don’t want to be out in the open,” he said in a brief phone exchange. “I’ve got to go. I’ve got a business to run.”

In Monterey, Dr. Douglas Hulstedt is known as the doctor to see for families seeking medical exemptions. In a brief phone interview, he said he was worried about being targeted by the state medical board. “I have stuck my neck way out there just talking with you,” he said. Hulstedt does not give exemptions to every child he examines, he said, but does believe vaccines can cause autism — a fringe viewpoint that has been debunked by multiple studies.

In March, the online publication Voice of San Diego highlighted doctors who write medical exemptions, including one physician who had written more than a third of the 486 student medical exemptions in the San Diego Unified School District. District officials had compiled a list of such exemptions and the doctors who provided them.

State Sen. Richard Pan (D-Sacramento), a pediatrician who sponsored California’s vaccine law, has been a vocal critic of doctors he says are skirting the intent of the legislation by handing out “fake” exemptions. Last month, he introduced follow-up legislation that would require the state health department to sign off on medical exemptions. The department also would have the authority to revoke exemptions found to be inconsistent with CDC guidelines.

“We cannot allow a small number of unethical physicians to put our children back at risk,” Pan said. “It’s time to stop fake medical exemptions and the doctors who are selling them.”

8 Common Arguments Against Vaccines And why they don’t make any sense at all

Gid M-K noted that because whilst vaccines have been accepted by public health organizations the world over as the most important medical innovation of the 20th century, and one of the most lifesaving interventions that we’ve ever come up with, there is a small minority of people who are convinced that vaccines are bad for their child’s health.

A small, very vocal, minority but this minority is causing real problems for others as well as their own kids.

One would like not to criticize parents. Because it’s very important to note that most parents want the best for their kids. They are trying to look out for their children, and occasionally in this pursuit, they get misled. And make no mistake, the people who sell vaccine fear are professionals in the art of deception. They know exactly how to convince a worried parent that the most dangerous thing in the world for their child is the vaccine, rather than, say, the measles.

It’s not the parents who are spreading vaccine denial. They are victims of professionals. If you are a parent who is worried about vaccination: don’t stress. You are a good parent. You have just been lied to. Have a read of this article, and maybe go have a chat with your doctor about why immunization is important and why it’s a good thing for your kids.

Whenever you talk vaccines, the anti-vax professionals come up with the same arguments time and again. Let’s look at my top 8, and why they make no sense whatsoever:

8

Vaccines Cause Autism. I’m not really going to go into this, because it has been refuted time and again. Virtually every study involving a) humans, b) more than 10 participants, and c) researchers who haven’t been convicted of fraud, has shown that there is no link between vaccines and autism. It was a valid concern in the early 90s, but we have 30 years of evidence showing that autism is in no way linked to vaccines.

VACCINES DO NOT CAUSE AUTISM ALL REPUTABLE STUDIES HAVE SHOWN THIS FOR DECADES

7

There Hasn’t Been Much Research. This is always a bit of a weird one because people are usually claiming that on the one hand there hasn’t been enough research done on vaccines to prove them safe, but on the other, they know the truth because they’ve done their research and it shows vaccines to be basically poison.

It’s a strange argument to make, but it comes up all the time.

This is simply a lie told by vaccine-deniers to make parents scared. Vaccines are one of the most well-researched interventions of all time. We have data from literally millions of children across the world demonstrating their safety. There has been more research on vaccines than almost any other medical intervention.

The research has been done. Time and again. Vaccines are safe and effective.

6

Vaccines Are Enormously Profitable. This is also a weird one, because…so what? So are any number of things. The international flour market is gigantic, but that doesn’t make every bread advert a missive from the devil. Flour millers have actually been influential in protecting babies worldwide by fortifying their products with macronutrients and preventing neural tube defects.

It’s also untrue. Pharma companies make far more money from so-called ‘blockbuster’ drugs than vaccines — for example, AstraZeneca’s Nexium, despite being no more effective than cheaper options for gastrointestinal problems, has made them more than $50 billion. The yearly earnings have been somewhere between 2 and 5 times as much as the flu vaccine. In fact, if you look at the top 20 earners for pharma companies, not one of them is a vaccine.

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5

Vaccines Cost Loads. Perhaps more importantly than this, however: vaccines don’t cost much at all. Take the whooping cough vaccine. A full 3 doses costs around 100 USD. That seems like quite a bit until you remember that a single case of whooping cough can easily top $10,000if it requires significant treatment.

Vaccines are actually cost-saving. What this means is that for every dollar you spend on vaccines, you get about seven dollars back because you stop people from getting sick and dying from their illnesses. Generally speaking, it would be much more profitable for the medical industry to not vaccinate, because the disease tends to be really expensive.

4

The CDC Is Lying. This is one of my favorite red herrings because it is just so easy to disprove. Whenever someone brings up the CDC, my response is…so what? Let’s say the CDC is evil, awful, in the pocket of Big Pharma. It’s not — the people who work at the CDC are dedicated, honest, and usually incredibly good at public health — but for the sake of argument, let’s say the CDC is corrupt.

Who cares?

People who focus on the CDC ignore one glaring truth: the US isn’t the only country in the world. If the CDC is corrupt, what about every other public health organization in the world that recommends vaccines. Australia. France. The UK. Japan. China. The list goes on. Forget about the CDC. Have a look at the Australian Department of Health on vaccines. Or the Japanese immunization schedule. Or one of the hundreds of other countries that all choose to vaccinate. Either there’s a global conspiracy including countries that are literally at war with one another — a bit unlikely — or immunization is a good thing no matter what you think of the CDC.

3

The US Is Special. This is another one that I love because it’s so easily disprovable. No, the US doesn’t give a uniquely high number of immunizations. Much of the OECD has a virtually identical vaccine schedule to the US, bar a few minor differences. The US also has significantly less punitive laws in terms of vaccination than other countries — for example, in France, you can go to jail for failing to vaccinate your kids.

So no. The US isn’t special. It’s just another country, trying to stop nasty diseases like polio, diphtheria, and measles from killing children.

2

Vaccine Manufacturers Can’t Be Sued For Making Kids Sick. This is actually a very simple lie. You can sue whoever you want, even in the US. What the 1986 National Childhood Vaccine Injury Act actually does is make it much easier to get compensation for children who have suffered vaccine injuries. If you can demonstrate that you had a vaccine and suffered a recognized issue — let’s say anaphylaxis — there is a reasonably simple method of gaining access to compensation in the US.

Elsewhere in the world, for example, Australia, often all you can do is sue in civil courts. And even if you’ve suffered genuine harm from vaccination, proving this in a court of law is next to impossible, meaning that people who do suffer injuries are almost never compensated.

It’s also worth noting that saying “vaccine manufacturers can’t be sued” is again a uniquely American piece of nonsense. There are hundreds of other countries. Most of them allow anyone to try and sue anyone. And yet, the UK court system isn’t flooded with cases of vaccine manufacturers being successfully sued.

I wonder why?

1

Vaccine Injury Is Common/People Are Getting Sicker. Last but not least, the most common one of the bunch. Forget the CDC, forget the pharmaceutical companies, this is the real evil.

Every year, people are getting sicker. And it’s all down to vaccines.

There are two parts to this story. Firstly, we aren’t getting sicker. Not even a little bit. Life expectancy is marching steadily upward, with some people predicting that we will be living past 100 in this century. Not only that, but infant and child mortality is at record lows, and is only heading swiftly down. This isn’t just true for wealthy countries mind you — the entire world is getting stubbornly healthier.

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Secondly, vaccine injury is an amazingly well-researched field. We know the rate of injuries associated with vaccines all too well. It’s a roughly 1 serious problem for every million vaccinations given. This is a number that has been replicated worldwide, from Japan to Thailand to Australia to Finland and yes, to the US.

Vaccines Rock

There’s not really much more to say. These are common arguments, mostly just based on simple lies. Vaccines are safe and effective, not because pharmaceutical companies say it’s so or because the CDC has proclaimed it, but because thousands of dedicated researchers the world over have spent decades checking to make sure that they are.

So go and get your kids vaccinated. It’s good for society, it will save us all money, but most of all it might save their life.

Vaccines rock.

It’s as simple as that. So, stop all your chest beating complaining about your constitutional rights being trampled on! Vaccinations are for the benefit of the children yours and those who will come in contact with non-vaccinated people and get severely sick. Cut it out and get vaccinated or suffer the consequences!!

Best wishes for the Easter and Passover holidays!

Healthcare in 2019: Divided

 

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

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

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

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

HHS and hospitals: It’s complicated

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

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

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

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

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

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

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

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

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

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

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

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

Hospital priorities for Congress: DSH payments

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

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

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

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

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

“Will they have the time?” he asked.

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

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

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

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

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

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

Pharmaceuticals: ‘It’ll be busy’

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

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

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

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

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

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

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

“It’ll be busy,” Greenwood said.

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

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

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

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

Insurers: Focus on the individual market

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

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

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

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

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

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

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

Dems hit GOP on health care with additional ObamaCare lawsuit vote

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GOP seeks health care reboot after 2018 losses

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Onward!!!

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

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

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

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

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

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

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

Opioid ‘Ground Zero’

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

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

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

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

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

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

An Unlikely Winner

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

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

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

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

Post-Election Plans

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

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

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

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

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

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

Questioning the 80/20 rule for healthcare

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Healthcare and the midterms: I’ve got you covered

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

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

Midterm elections 2018 at a glance

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

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

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

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

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

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

Status of Medicaid expansion states and work requirements

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

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

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

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

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

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

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

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

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

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

Healthcare reform issues

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

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

Affordable Care Act:

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

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

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

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

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

Pre-existing conditions:

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

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

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

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

Medicare for all:

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

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

Drug prices in America

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

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

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

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

Midterms 2018 ballot measures

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

Nurse-to-patient staffing ratios in Massachusetts

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

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

Dialysis ballot measure in California:

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

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

Impact of immigration on healthcare

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

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

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

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

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

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

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

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

Republican Doublespeak on Health Care Starts at the Top, And now Uber Finds a Way to get into the Healthcare Business-Ha, ​Ha!!

44342794_1752462594883392_1210998589254270976_nMax Nisen for Bloomberg noted that as much as one may not like Obamacare and the sustainability of the system one must appreciate the need for the pre-existing conditions issues. This issue n most insurance policies makes it unaffordable for patients and an out for the insurance companies who always are making money.Untitled.preconditions.1

Republican Doublespeak on Health Care Starts at the Top

(Bloomberg Opinion) — If anyone needed more evidence that Republicans are nervous about health care’s impact on this year’s midterm elections, the president provided it Thursday afternoon.

All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support. Also, Democrats will destroy your Medicare, and I will keep it healthy and well!

In the real world, President Donald Trump’s Justice Department is arguing in court that the Affordable Care Act’s protections for pre-existing medical conditions are unconstitutional and should be nullified. On top of that, his administration explicitly supported a bill passed by House Republicans that would have weakened those protections.

Senate Majority Leader Mitch McConnell is also trying to have it both ways, claiming this week that Republican Senators universally support protecting people with pre-existing conditions, while voicing his support for the lawsuit and another repeal effort.

Democrats recognize that the GOP is vulnerable and conflicted on health care, and its candidates are devoting millions of dollars worth of ads to it. It’s not the only thing helping to give Democrats a strong chance of taking back the House. But it’s a key driver.

Trump and Senator McConnell are far from alone in touting their support for protecting pre-existing conditions while having voted or worked to dismantle the ACA. Many other candidates are doing the same tap dance, and are even running ads touting their support for the policy. The GOP candidates for Senate in tight races in Missouri and West Virginia are current attorneys general who is supporting the controversial lawsuit.

It’s easy to see why everybody’s anxious. The ACA’s robust protections for people with pre-existing conditions are highly popular. In a recent Kaiser Family Foundation poll, more than 70 percent of Americans agreed that it was “very important” that they remain law.

That gets at the heart of Republicans’ dilemma: It’s one thing to promise an end to Obamacare’s burdensome regulations while vowing to lower premiums and maintain patient protections. But it’s actually a phenomenally difficult policy problem, and the GOP hasn’t offered a proposal that solves it.

The ACA prohibits insurers from denying coverage to people with pre-existing conditions and from charging them more for it, ensures that all plans cover a core roster of benefits including mental-health treatment and maternity care, and bans lifetime and annual coverage limits. It supports those protections and insurers by attempting to create a large risk pool and subsidizing insurance for people with lower incomes.

If you cut out any part of that, the door likely opens for insurers to offer skimpier insurance, siphon off healthy people, and leave those with pre-existing conditions with less appealing or more expensive options. The administration is currently doing that on a smaller level by pushing cheaper but less comprehensive short-term insurance plans.

It’s theoretically possible to protect people with pre-existing conditions in other ways. But they almost certainly involve trade-offs. The one that the GOP has generally tended to favor recently is weakening protections for people with pre-existing conditions in order to lower costs for healthy people.

No GOP candidate wants to say that out loud, to admit that their definition of protection is different and less comprehensive than the status quo. Democrats are spending a lot of money to make the distinction clear.

Pre-existing conditions aren’t the only health-care sore spots for the GOP.

In past years, Republicans have run on the idea that Obamacare’s individual market is an irredeemable failure, bolstered by soaring premiums. But premiums have stabilized or declined and insurers are increasingly profitable, making it more difficult to assail the law. Premiums would be lower if the GOP hadn’t spent years deliberately undermining the market.

And referendums on the law’s Medicaid expansion, which has dramatically expanded coverage for vulnerable Americans in more than 30 states, are on the ballot in Utah, Nebraska, and Idaho. It’s implicitly on the ballot in others, where changes in the composition of state governments could push states toward expansion, or in the other direction toward Arkansas-style work requirements that push people off of the program.

If the House flips and Democrats hold Senate seats in West Virginia and Missouri, states that Donald Trump won by 42 and 19 points respectively, it’s a sign that the GOP needs to rethink its approach to health care.

Obamacare is finally working (and Republicans still want to kill it)

Rick Newman noted that President Trump might not mind if people starting calling Obamacare Trumpcare because the controversial health program signed into law in 2010 are finally stabilizing.

After several years of sharp rate hikes, insurance premiums for people participating in Affordable Care Act exchanges are actually due to fall in 2019. The Trump administration says the average premium for a typical plan will drop by 1.5% next year. That’s based on rates insurance companies must file with the states in which they operate. About 9 million Americans buy insurance on an ACA exchange.

“There’s been a lot of tumult under the ACA up till now,” says Larry Levitt, a senior vice president at the Kaiser Family Foundation. “But there’s no question it’s viable, in the face of significant headwinds. The ACA is embedded in the health care system.”

Insurance still isn’t cheap. The average monthly premium for a mid-level “silver” plan under the ACA will be $406 next year—69% higher than the average premium just three years ago. But steadier rates indicate that insurers have finally figured out how to properly price the policies sold on the exchanges. When the ACA first went into effect in 2014, insurers underpriced their plans. That forced them to impose sharp price hikes in subsequent years. The dramatic price swings might finally be over.

Most ACA participants receive subsidies that protect them from price hikes. But people who earn too much money to qualify for subsidies, and don’t get coverage through an employer, have gotten clobbered with soaring premiums in recent years. A married couple in their 50s can easily pay $25,000 per year in premiums alone. About 6.7 million Americans buy unsubsidized insurance on their own.

The stabilization of the ACA is actually an awkward development for Trump, who campaigned to repeal the law and has boasted that “piece by piece, Obamacare is just being wiped out.” Trump has tried to dismantle the ACA by cutting outreach and educational programs and killing reimbursements to insurance companies meant to cover the cost of low-income enrollees. Last year’s Republican-backed tax-cut bill killed the individual mandate requiring everybody to have health care coverage, effective at the start of 2019. That will probably reduce the number of people with coverage under the ACA.

More consumers approve of the ACA

Republicans, of course, came close to overturning the whole law last year—and may try again, if they retain control of Congress after this year’s midterm elections. Senate Majority Leader Mitch McConnell told Reuters recently, “if we had the votes, we’d do it.”

The public doesn’t actually want that, however. Approval of the ACA has gradually drifted up from a low of 33% right before the law went into effect in 2014, to 48% in the latest Kaiser Family Foundation poll. The disapproval rate was 40%, with 11% saying they don’t know. The law could get more popular once the individual mandate is formally gone since that was one of the law’s most controversial measures.

Health care is turning out to be a potent issue in this year’s midterm elections, with 71% of respondents saying in a Kaiser poll that it’s a “very important” factor in terms of who they will vote for. That’s more than any other issue. Jobs and the economy, normally the top concern, came in second, with 64% saying it’s very important.

Democrats think they have the edge on health care, since they generally support the ACA, along with provisions that would make it work better, such as measures to make insurance cheaper for people who don’t qualify for ACA subsidies. And many Democrats now support some version of the Bernie Sanders “Medicare for all” plan, which would extend the health program for seniors to others who don’t have coverage.

Trump, for his part, has allowed more narrow insurance plans, which were generally banned under the ACA, as a way to let some people pay less for less generous coverage. But Trump’s administration has also joined a lawsuit seeking to overturn one of the most popular parts of the ACA—a provision saying insurance companies cannot deny coverage or charge exorbitant fees to enrollees with pre-existing conditions. The details are complicated, but if Trump’s side wins, some states will probably go back to the old rules of allowing insurance companies to charge whatever they want. The politics of health care seems to have a lively future.

Aging undocumented immigrants pose costly health care challenge

Tersea Wiltz working for CNNMoney recently wrote that early on a recent morning, men huddle in the Home Depot parking lot, ground zero for day laborers on the hunt for work. Cars pull into the lot, and the men swarm.

Among them is Marcos, at 65, wiry and bronzed with a silvery smile. He’s been in the country illegally for 20 years. When he’s sick, he just rests, because — like most undocumented workers — he doesn’t have insurance.

“I don’t know if I have high blood pressure,” he said. “Because I don’t check. Doctors, you know, are expensive.”

For decades, the United States has struggled to deal with the health care needs of its undocumented immigrants — now an estimated 11 million — mainly through emergency room care and community health centers. But that struggle will evolve. As with the rest of America, the undocumented population is aging and developing the same health problems that plague other senior citizens.

Many undocumented adults lack health insurance, and even though they’re guaranteed emergency care, they often can’t get treated for chronic issues such as high blood pressure. What’s more, experts predict that many forgo preventive care, making chronic conditions worse — and more expensive to treat.

“They’re hosed. If you’re an undocumented immigrant, you’re paying into Social Security and Medicare, but can’t claim it,” said Steven Wallace of the UCLA Center for Health Policy Research.

When uninsured people end up in the hospital, that pushes up rates for those who have insurance. Or public programs like Emergency Medicaid pick up the tab. This contributes to a game of shifting costs, Wallace said.

“It’ll place a strain on the entire health care system,” Wallace said.

Growing numbers

Approximately 10% of the undocumented population is over 55 now, according to the Migration Policy Institute, but researchers agree that their numbers will rise.

“The unauthorized immigrant population has become more settled, and as a result is aging,” said Mark Hugo Lopez of the Pew Research Center.

Estimates vary on how many undocumented immigrants lack insurance. The Kaiser Foundation estimates 39 percent are uninsured, while the Migration Policy Institute, which analyzes U.S. Census data, estimates as many as 71 percent of undocumented adults do not have insurance.

Like Marcos, older undocumented people tend to be poor. The Affordable Care Act doesn’t cover them, and they don’t qualify for Medicaid, Medicare or Social Security, even though many pay taxes. Few can afford private insurance.

That means most must turn to emergency rooms or community health centers, which provide primary care to poor people, regardless of immigration status. But community health centers can’t provide extensive care, Wallace said. And because Congress has yet to fund them, their future is precarious.

Leighton Ku, professor, and director of the Center for Health Policy Research at George Washington University said immigrants, both authorized and unauthorized, are much less likely to use health care than are U.S. citizens. Until that is, they’re quite ill.

“Their numbers are going to grow and we’re going to have an epidemic on our hands,” said Maryland state Del. Joseline Peña-Melnyk, a Democrat. “Who’s going to pay for it?”

A 2014 report by the Texas Medical Association found that undocumented immigrants with kidney disease face considerable barriers to care. By the time they do get help, they need dialysis, costing Texas taxpayers as much as $10 million a year.

Stepping in to help

Many cities have tried to step in. A 2016 Wall Street Journal story noted that 25 counties with large undocumented populations provide some non-emergency health care to these immigrants, at a combined cost of what the paper estimated is more than $1 billion each year.

Washington, D.C., Los Angeles and San Francisco are among the places where undocumented immigrants can usually get routine care, thanks to locally funded programs.

In Los Angeles, Dr. Christina Hillson, a family practice doctor at the Eisner Health Clinic, said she’s seeing a growing number of elderly undocumented patients, whom she’s treated for everything from ovarian cancer to amputations resulting from untreated diabetes.

Patients who are critically ill are considered emergencies and can get treated at hospitals, she said. Sometimes Hillson will send patients who aren’t as ill to the ER because it’s the only way they can see a specialist.

Snapshot of a population

Most undocumented people immigrated here when they were young and tended to be healthier than native-born citizens, Wallace said. But as they age, they lose that advantage.

Undocumented women are more likely to have family in the U.S., who can help care for them as they age, said Randy Capps of the Migration Policy Institute. But men are more likely to be single. Because they often work as manual laborers, they’re more likely to get hurt on the job, Capps said.

“They’re going to age faster and become disabled at higher rates,” Capps said. “It’s going to make for a much tougher old age.”

There’s no one easy solution to helping older residents who live in the United States illegally, health and immigration experts say.

“The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem,” said Steven Camarota of the Center for Immigration Studies, which favors limiting immigration.

Joe Caldwell of the National Council on Aging, an advocacy group, said federal immigration legislation providing a pathway to citizenship would allow seniors to access care.

Such legislation is unlikely any time soon.

Outside the Home Depot, Marcos and his friends gather in the cold sunshine. He’s been paying taxes for years, Marcos said, and he’s got pages of documents to prove it. He’d love to become documented, “but that’s practically impossible,” he said.

A year ago, Marcos said, he had tightness in his chest. He had no choice but to go to the ER, but he hasn’t followed up. He’d rather stalk the parking lot here, looking for work.

“No work,” Marcos said, “no money.”

Uber Offers In-Hospital Patient Transport with UberGURNEY

I thought that we all needed to take a break from the serious depressing news around us and from this article from a satirical blog site and I hope that it will bring a smile to all. Uber’s success knows no bounds. After infiltrating cities across the world with their groundbreaking online-based transportation service, Uber “is” infiltrating hospital buildings with their new fleet of UberGURNEY vehicles, giving patients more options to get from point A to point B within a hospital. Wow, remember they already offer rides to your physician or clinic or even to your hospital as long as you don’t need special care. So is this the next step?!?UberGURNEY-e1476480255783“Look, we’ve conquered roads all over the world,” said Uber founder Travis Kalanick.  “What’s next?  The hospital corridors of the world.  Patients and nurses waste precious hours of their lives waiting for patient transport to arrive, whenever that is.  Not with UberGURNEY.  Just tap the app and we’ll pick you up.”

UberGURNEY does not require downloading a separate app, as UberGURNEY simply appears as another transport choice alongside UberPOOL, UberX, UberXL, and UberBLACK.  Trial runs conducted at Uber’s hometown hospital, the University of California at San Francisco, have garnered positive feedback.

Nurse Connie Jenkins explains.  “Endoscopy called me that my patient should be sent down.  I called for patient transport but no one picked up.  My patient had the Uber app, requested an UberGURNEY, and was picked up in 2 minutes.  It may not sound like much, but any minute shaved off for someone NPO can save a life.”  Jenkins is referring to an unfortunate incident earlier this year when a patient claimed he was starving to death after 1 hour NPO and actually died of hunger 1 hour later.

Feedback from patients has generally been positive as well.

“I really needed a turkey sandwich bad,” explained patient Ollie Nelson, rubbing his tummy with conviction.  “I gave UberGURNEY a whirl.  In three minutes, a driver picked me up and took me from my room to the cafeteria.  It was fantastic.”  Nelson did note one issue, however, a complaint about many long-time Uber users.  “After I ate my sandwich, it was like 5 PM.  Those surge prices are for real!  Fifty bucks just to get back to my room!  Maybe I should’ve walked.”

UberGURNEY will be rolling out in major academic institutions nationwide, including the Mayo Clinic, who revolutionized the transport game in 2014 with their pneumatic tube system for patient transport.  UberGURNEY is in its early stages but should it reproduce the success of its car service, Uber expects to offer an expanded fleet of UberGURNEYs with UberGURNEYBLACK for those who are willing to pay more for a private gurney and UberBODYBAG for those unfortunate patients who have died and wish to head to the morgue immediately.

Now imagine the self-driving cars picking you up and then transporting you around the hospital in driverless gurneys and our patients cared for by robot docs and nurses. Think about computer APPs and telemedicine, which is already here. Unbelievable!! Stay tuned!!

The Fiscal Burden of Illegal Immigration on United States Taxpayers including the Health Care System

44430232_1751281151668203_4321873792935657472_n-2I thought with the impending influx of the huge group of immigrants moving toward to the U.S. border, that we should look at the real impact. This is a fairly long post but one that “needs to be told”. Matt O’Brien and Spencer Raley reported on the continually growing population of illegal aliens, along with the federal government’s ineffective efforts to secure our borders, present significant national security and public safety threats to the United States. They also have a severely negative impact on the nation’s taxpayers at the local, state, and national levels. Illegal immigration costs Americans billions of dollars each year. Illegal aliens are net consumers of taxpayer-funded services and the limited taxes paid by some segments of the illegal alien population are, in no way, significant enough to offset the growing financial burdens imposed on U.S. taxpayers by massive numbers of uninvited guests. This study examines the fiscal impact of illegal aliens as reflected in both federal and state budgets.

The Number of Illegal Immigrants in the US

Estimating the fiscal burden of illegal immigration on the U.S. taxpayer depends on the size and characteristics of the illegal alien population. FAIR defines “illegal alien” as anyone who entered the United States without authorization and anyone who unlawfully remains once his/her authorization has expired. Unfortunately, the U.S. government has no central database containing information on the citizenship status of everyone lawfully present in the United States. The overall problem of estimating the illegal alien population is further complicated by the fact that the majority of available sources on immigration status rely on self-reported data. Given that illegal aliens have a motive to lie about their immigration status, in order to avoid discovery, the accuracy of these statistics is dubious, at best. All of the foregoing issues make it very difficult to assess the current illegal alien population of the United States.

However, FAIR now estimates that there are approximately 12.5 million illegal alien residents. This number uses FAIR’s previous estimates but adjusts for suspected changes in levels of unlawful migration, based on information available from the Department of Homeland Security, data available from other federal and state government agencies, and other research studies completed by reliable think tanks, universities, and other research organizations.

The Cost of Illegal Immigration to the United States

At the federal, state, and local levels, taxpayers shell out approximately $134.9 billion to cover the costs incurred by the presence of more than 12.5 million illegal aliens and about 4.2 million citizen children of illegal aliens. That amounts to a tax burden of approximately $8,075 per illegal alien family member and a total of $115,894,597,664. The total cost of illegal immigration to U.S. taxpayers is both staggering and crippling. In 2013, FAIR estimated the total cost to be approximately $113 billion. So, in less than four years, the cost has risen nearly $3 billion. This is a disturbing and unsustainable trend. The sections below will break down and further explain these numbers at the federal, state, and local levels.

Total Governmental Expenditures on Illegal Aliens

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Total Tax Contributions by Illegal Aliens

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Total Economic Impact of Illegal Immigration 

Untitled.jpg.undoc.3Federal

The Federal government spends a net amount of $45.8 billion on illegal aliens and their U.S.-born children. This amount includes expenditures for public education, medical care, justice enforcement initiatives, welfare programs, and other miscellaneous costs. It also factors in the meager amount illegal aliens pay to the federal government in income, social security, Medicare and excise taxes.

FEDERAL SPENDING

The approximately $46 billion in federal expenditures attributable to illegal aliens is staggering. Assuming an illegal alien population of approximately 12.5 million illegal aliens and 4.2 million U.S.-born children of illegal aliens, that amounts to roughly $2,746 per illegal alien, per year. For the sake of comparison, the average American college student receives only $4,800 in federal student loans each year.

FAIR maintains that every concerned American citizen should be asking our government why, in a time of increasing costs and shrinking resources, is it spending such large amounts of money on individuals who have no right, nor authorization, to be in the United States? This is an especially important question in view of the fact that the illegal alien beneficiaries of American taxpayer largess offset very little of the enormous costs of their presence by the payment of taxes. Meanwhile, average Americans pay approximately 30% of their income in taxes.

Map: Illegal immigration costs California most, $23B, all states $89B

Now a break down of costs by state. Paul Bedford noted that the illegal immigration costs taxpayers in all 50 states a total of $89 billion, and California, where an illegal on Thursday was cleared of murdering Kate Steinle despite admitting to the shooting, pays the most at $23 billion, according to a new map of the costs.

The website HowMuch.net, working with figures from the Federation for American Immigration Reform, found that Californians pay more than twice as much for illegal immigrants than the next closest state, Texas, where the price tag is $11 billion.

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The costs cover added expenditures for education, welfare, law enforcement, and medical care.

When federal costs are included, the price tag nationally soars to $135 billion a year.

FAIR’s data also includes the offset of taxes paid by illegal immigrants, though the numbers are much lower. In the state and local column, they are $3.5 billion. Nationally they are $15 billion.

Overall, the costs associated with illegal immigrants is much higher for state and local governments than the federal government. States pay $89 billion, Uncle Sam, $46 billion.

The states paying the most to care for illegals:

  1. California – $23,038,125,353
  2. Texas – $10,994,614,550
  3. New York – $7,489,141,357
  4. Florida – $6,290,429,108
  5. New Jersey – $4,466,838,574
  6. Illinois – $3,220,767,517
  7. Georgia – $2,487,719,503
  8. North Carolina – $2,437,965,113
  9. Maryland – $2,378,996,947
  10. Arizona – $2,314,131,964

Focusing on Healthcare Costs of Illegal Immigrants Draws Attention Away from the Real Problem

Too many illegal immigrants are overwhelming the health care system and driving up health insurance costs. That’s the latest sound bite in the war of words over immigration reform. In a recent poll, a majority of the respondents thought that illegal immigrants were responsible for 50 percent or more of the uninsured treated in Southern California hospitals. But is that really the case?

While it is true that providing treatment to undocumented immigrants creates a drain on hospital resources, the question is: How much of the problem can reasonably be attributed to the undocumented? And if we solved the problem of illegal immigration tomorrow — which we won’t — would health care costs return to “reasonable” levels?

Illegal immigrants are responsible for roughly 20 percent of the $2 billion in unreimbursed care that Southern California hospitals deliver each year. Even if you consider that factor, you have to conclude that it’s the larger problem of just simply having so many uninsured patients that is a key driver of rising hospital costs.

In order to receive federal Medicare and Medicaid payments, a hospital must agree to treat and stabilize everybody who shows up to a hospital ER regardless of their ability to pay or their immigration status. That means undocumented immigrants who show up at the emergency room will receive treatment regardless of their immigration status or whether they’re insured. But so will legal immigrants, naturalized citizens and native-born Americans.

It is a matter of law that these people receive treatment. Indeed, we may have an ethical responsibility to do so as well. The problem is that most hospitals in California end up being paid for only about 5 percent of the medical care given to uninsured patients. And that leads to the question: So, who’s going to pick up the tab?

In the absence of strong political leadership on the question of insuring the uninsured, the answer, inevitably, is that hospitals and those patients with insurance, as well as those uninsured who do pay, will end up paying for those who seek care without insurance — regardless of whether they are here legally or not.

An ironic healthcare twist for undocumented immigrants

The University of Michigan Medical School study noted that the undocumented immigrants are in the country illegally. Or maybe they had protected status before but lost it due to policy changes by the current presidential administration.

Or they’re waiting for word from Congress or the courts on whether they’ll get to stay.

Whatever their situation under the law, the 11.3 million undocumented immigrants currently in the United States still need, and sometimes get, health care.

Even if they don’t have health insurance, federal law requires hospitals to care for them in emergencies. They can turn to safety-net clinics for basic needs.

Now, a new analysis highlights an ironic development in the intertwined issues of immigration and health care – two areas where the current and previous administrations differ greatly.

Undocumented people in certain states may get more medical help while they are here, it finds, thanks to the current administration’s effort to give states more flexibility with their health care spending. And in a reversal of the previous administration’s stance, states may find it easier to get that permission.

In a new article in the New England Journal of Medicine, two members of the University of Michigan Institute for Healthcare Policy and Innovation unpack recent events, political philosophies and medical evidence about caring for the undocumented.

They conclude that more states may want to apply for permission to use state and federal dollars to pay safety-net hospitals that care for everyone – whether or not they are here legally.

Waivers already in action

Such permission, which requires the government to approve an application called a waiver, has already gone into effect in Florida and Texas.

As two of the states with the highest numbers of undocumented immigrants living in their borders, they’ve seen the amount of money they can award to safety-net hospitals rise by 50 percent to 70 percent.

“Ironically, the same administration that is targeting undocumented immigrants with one set of policies may be helping them get care by preserving hospitals’ abilities to serve them with other policies,” says A. Taylor Kelley, M.D., M.P.H., who led the analysis.

Kelley says their example may bode well for other states that, like Florida and Texas, didn’t choose to expand Medicaid under the ACA.

“The United States has one of the highest rates of uninsured people in the world among developed countries, and the Affordable Care Act was designed to increase health insurance options for men, women, and children across the country. But undocumented immigrants were excluded,” so they can’t enroll in Medicare or Medicaid, or buy a plan on the ACA marketplace, explains Kelley, who is a clinical lecturer in general internal medicine at the U-M Medical School and a National Clinician Scholar at IHPI.

“Undocumented immigrants rely on safety-net institutions that deliver care for people, with insurance or without insurance,” he explains. “Safety net hospitals are also major employers and economic drivers in their communities. And so to keep their doors open, states can seek federal permission to increase the funding they get. And generally, the current administration has been very receptive.”

States didn’t get a warm welcome from the Obama administration for such waivers, because that administration’s priority was encouraging states to expand Medicaid coverage to all low-income adults – or at least those who had legal status. In fact, the previous administration said it would take away existing funding for safety-net hospitals in states that didn’t expand Medicaid.

Florida actually decided to redirect some of its own funds to help its hospitals, rather than expand Medicaid, when its waiver was ended by the Obama administration.

A door closes, a door opens 

But with the change in administrations, Kelley and co-author Renuka Tipirneni, M.D., M.Sc., write, the states that didn’t expand Medicaid and have high numbers of undocumented residents may find it easier.

States along the Mexican border, for instance, may want to seek a waiver – or apply to take part in a program that incentivizes new care delivery models for poor patients.

As for the states that did expand Medicaid, only time will tell if the government will also approve waivers to further ease the financial burden on safety net hospitals and clinics there.

A recent IHPI report about Michigan’s Medicaid expansion finds that while hospitals saw their uncompensated care drop by an average of 50 percent in the first year after expansion, the level has stayed flat since that time.

So hospitals are still absorbing the cost of caring for many people who can’t pay their medical bills, whether it’s because they have no insurance or they can’t afford the part of their bill that their insurance expects them to pay. Around half of the undocumented immigrants in the U.S. lack insurance of any kind, according to estimates.

“The major question when talking about state flexibility is, where are the limits? And how much are we going to honor states’ rights?” says Kelley. “Both Medicaid expansion and support for the safety net are programs where states are now being given the autonomy to act as they feel best for the people within their borders. Will these approaches be honored by the administration as a state right?”

Spending up front, or later 

At the same time, Kelley notes, the inpatient hospitals that have historically received the waiver funds are more and more likely to be part of new network-based models of care, such as accountable care organizations, which makes it easier for them to offer integrated care for those who come through the doors of their emergency rooms.

That may mean it’s easier to care for undocumented immigrants in a preventive or early-stage way, rather than waiting for an emergency.

In addition, Congress recently extended funding for federally qualified health centers that provide care to underserved patients outside of the hospital.

Such care can actually save money, according to research cited in the new piece. For instance, one study showed that states can save money by covering dialysis care for undocumented immigrants whose kidneys are failing, rather than waiting to provide the legally required emergency dialysis when they are in crisis. Illinois has even gone so far as to cover kidney transplants for undocumented people, because of the potential long-term cost savings.

Other research shows that expansion of individual insurance coverage provides better outcomes and use of resources than insurance for some and no insurance for others who must turn to safety net care, says Kelley. But the political philosophies and policy stances of current leadership don’t make expanded coverage likely right now.

“We’ve come out of eight years of one way of thinking, now we’re in a new way of thinking,” says Kelley. “And it’s a new shift for states if they’re going to cover the people they need to cover and help institutions out, then they have to shift their focus and their thinking.”

“Some might ask, what does care for the undocumented have to do with me as an American citizen. And the reality is that, because we provide care to anyone who stands in need of a health emergency, we all pay for everyone’s healthcare sooner or later,” he says. “When we provide access to care for undocumented immigrants, it’s not necessarily going to be a cost burden every time. In some ways, it may be beneficial to us in both indirect ways and even in direct ways.”

The impact of undocumented workers on health care costs

The Pew Charitable Trusts recently outlined the quietly building demand that undocumented workers will place on the health care system as they age.

Dan Cook of Benefitspro.Com reviewed a 2014 report which found that undocumented immigrants who needed kidney dialysis cost Texas taxpayers $10 million—much of which could have been avoided, had the immigrants been able to treat their disorders upstream. Talk about a one-two punch to the U.S. healthcare system’s gut. First, there are the widely publicized 40 million new clients that will enter Medicare’s ranks by 2050 as Baby Boomers age into the system. Then, there’s the much less publicized, but still ominous, aging undocumented worker wave about to hit the system.

This group, representing millions of illegal immigrants, is for the most part uninsured. To date, its members have made few demands on a system they don’t trust and can’t afford. But as they age and their health breaks down, they will find the system, and in all likelihood, enter through its most expensive doors: the ER or hospital admissions. Unable to pay for the care they receive, their cost will be shifted to the same health systems and insurers already panicking about how to care for those with coverage.

The Pew Charitable Trusts outlined this quietly building demand in its Stateline publication. An article entitled Aging, Undocumented and Uninsured Immigrants Challenge Cities and States reviewed research on the healthcare needs these estimated 11 million undocumented residents will have as they grow older in America. Because most don’t even qualify for Medicaid, they will be forced to go to hospitals and emergency rooms for treatment as conditions that have gone untreated worsen with age. And, the article concluded, the current health care model in the U.S. makes no provision for covering the cost of their care beyond shifting it to those with coverage.

“… Senior citizens without documentation don’t have access to care for chronic issues such as kidney disease and high blood pressure. What’s more, experts predict that many will forgo primary preventive care even when it is available, likely making their chronic health problems worse — and more expensive to treat,” the article said.

Author Teresa Wiltz noted that there are pockets across the U.S. where local communities have addressed this coming crisis with local dollars. Washington, D.C., Los Angeles and San Francisco have developed funding streams for programs that make regular health check-ups and treatment available and affordable to immigrants regardless of their status.

But throughout most of the U.S., the health of undocumented workers remains invisible. That is until somebody puts a number on it.

The Pew article cites statistics from Texas, an especially difficult state for undocumented workers to receive regular or preventive health care. There, a 2014 report found, undocumented immigrants who needed kidney dialysis and couldn’t pay for it cost state taxpayers $10 million—much of which could have been avoided had the immigrants been able to treat their disorders upstream.

What’s the solution? Conservatives tend to default to the “go back to from where you came” strategy. “The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem,” Steven Camarota, director of research for the Center for Immigration Studies, a conservative think tank that favors limiting immigration, told Stateline.

For others of a more liberal bent, the answers aren’t so off-the-shelf. Community health centers could be expanded and encourage more illegal immigrants to get regular care. Federal policies could be loosened to open up Medicaid or other options. Becoming a citizen should be made easier, especially for seniors, say others.

Meantime, hospitals and insurers play the cost-shifting game and hope for help from the nation’s capital—where the political wrangling over individual health care access seems unaffected by the looming crisis brought on by aging Americans.

The Affect on Texas

Rohit Kuruvilla and Rajeev Raghaven, doctors at Baylor College of Medicine researched the impact on Texas and found the providing health care to the 1.6 million undocumented immigrants in Texas is an existing challenge. Despite the continued growth of this vulnerable population, legislation between 1986 and 2013 has made it more difficult for states to provide adequate and cost-effective care. As this population ages and develops chronic illnesses, Texas physicians, health care administrators, and legislators will be facing a major challenge. The new legislation, such as the Affordable Care Act and immigration reform, does not address or attempt to solve the issue of providing health care to this population. One example of the inadequate care and poor resource allocation is the experience of undocumented immigrants with end-stage renal disease (ESRD). In Texas, these immigrants depend on safety net hospital systems for dialysis treatments. Often, treatments are provided only when their conditions become an emergency, typically at a higher cost, with worse outcomes. This article reviews the legislation regarding health care for undocumented immigrants, particularly those with chronic illnesses such as ESRD, and details specific challenges facing Texas physicians in the future.

Introduction- The undocumented immigrant population in Texas has been increasing since 2008 with a current estimate approaching 1.6 million persons.1 Although this may be attributed primarily to proximity to the US-Mexico border, the favorable growth of the Texas economy and the creation of low-wage jobs predicts a continued increase along this path over the next decade.  Addressing the health care needs of undocumented immigrants and their families constitutes an existing problem that is solved currently by a patchwork of clinics, safety net hospital systems, and uncompensated charity care. We expect this problem to increase as this population ages and develops costly chronic illnesses such as obesity, diabetes, heart disease, kidney disease, and cancer. Unfortunately, forthcoming national health care and immigration reform legislation do not adequately address the issue of health care for this population.

Undocumented immigrants with end-stage renal disease (ESRD) represent a patient population at the center of this problem. These patients require dialysis treatments several times a week for survival. The lack of a uniform national policy to cover the cost of dialysis for noncitizens forces local health care systems into the ethical dilemma and financial challenge of providing adequate, cost-effective care for these patients. Not surprisingly, the type and frequency of dialysis treatments that an undocumented immigrant receives vary between El Paso and Houston, and even within a particular city, such as Houston.

This article reviews the past, present, and future legislation regarding health care for undocumented immigrants while describing the challenge of managing these patients with a chronic illness, such as ESRD.

Delivering Health Care to Undocumented Immigrants- The Pew Research Center estimates that 11.2 million undocumented immigrants reside in the United States. Approximately 14% of these persons live in Texas, and this number is expected to increase.1 Primary care is delivered to this population at 1 of the 69 federally qualified health centers (FQHCs) in Texas or via safety net hospital systems. Both locations care for uninsured and indigent patients, regardless of citizenship. The FQHCs receive money from the federal government and are equipped to provide both primary and preventative care. Safety net hospital systems (also called “county” or “public” hospitals) tend to be located in larger cities (e.g., Houston or San Antonio) and are funded by their specific county. Although they offer a multitude of services, including specialist care and elective surgeries, a longer wait time is usually involved. One unfortunate consequence of the current system is that patients often present to the emergency room with a more advanced disease due to lack of early diagnosis or treatment. The resulting health care costs more and is often either uncompensated or inadequately compensated.

Besides the relative lack of access to specialists, undocumented immigrants face cultural and social barriers in obtaining care. One major cultural barrier is language; more than 75% of undocumented immigrants come from Spanish-speaking countries, and most are not fluent in English. Two social barriers often encountered are difficulty keeping medical appointments because of an irregular work schedule and fear of deportation or exposure to the law.

Legislation- Between 1986 and 2013, many legislative documents have addressed the issues of health care and immigration. The various tables summarize the four most comprehensive acts, which are detailed below.

1986: Emergency Medical Treatment and Labor Act (EMTALA)- Signed in 1986, EMTALA stipulates that any person, regardless of his or her legal status, insurance status, or ability to pay, who presents to an emergency room must be medically stabilized before discharge or transfer. This law was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer. According to the law, an emergency medical condition is defined as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the person’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.”

1996: Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) – The “Permanent Residents Under Color of Law” (PRUCOL) status applies to persons whom the United States acknowledges are here illegally but for whom the country is not actively pursuing deportation. Under this status, these undocumented immigrants were granted access to many public benefits. However, in 1996, PRWORA eliminated classifying undocumented immigrants as PRUCOL status, effectively terminating their access to certain benefits (eg, welfare programs and Medicaid). Some states appealed this and continue to grant PRUCOL status to undocumented immigrants.  In California and Massachusetts, the PRUCOL status given to the undocumented immigrants allows them to receive certain health care benefits, such as scheduled dialysis. However, in Texas, undocumented immigrants are not given PRUCOL status and, hence, do not receive any public or health care benefits.

2013: Border Security, Economic Opportunity, and Immigration Modernization Act of 2013 (S 744)- Passed by the Senate in June 2013 by a vote of 68-32, this bill was awaiting approval by the House of Representatives as of May 2014. Its three primary goals are the following: to enhance border security, to renovate the immigration system by integrating the current undocumented immigrant population, and to streamline the citizenship process for highly skilled and educated persons.1 Ultimately, this bill will reduce the number of undocumented immigrants as a result of strengthened border security (adding 40,000 new agents to border patrol) and enforced hiring codes, while encouraging persons with broader educational achievement and economic potential to come into the United States through an extended visa program.

Undocumented immigrants who have lived in the United States since 2011 will be addressed as registered provisional immigrants (RPIs). After paying an initial $500 fee and any back taxes a person may owe, these immigrants may receive the RPI status if they have no criminal history. The RPI status must be extended after a 6-year probationary period. After 10 years, an RPI can apply for permanent residence, and at 13 years for citizenship. While the 13-year path to citizenship is an extended process, it affords current undocumented residents legal rights and provides them with a stable environment, relieving fears of deportation.

This act does not address health care for persons of RPI status. Hence, if this bill is signed into law, the challenge of providing care to undocumented immigrants will continue and may even increase as these persons will “come out of the shadows” and be more likely to seek primary, preventative health care and, eventually, specialist care.

2014: Patient Protection and Affordable Care Act- The Patient Protection and Affordable Care Act (ACA), also named Obamacare, has been under intense scrutiny and debate since its inception. Regarding health care for undocumented immigrants, RPIs, and persons on a visa, much debate has produced no conclusive answers. Obamacare was passed in 2010; it envisions complete national coverage by 2019 via a series of mandates, subsidies, and insurance exchanges. The act requires all legal residents to purchase insurance and penalizes those who do not. While Section 246 of the bill claims that “there shall be no federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States,” argument has ensued on where this places RPIs and how this will affect undocumented immigrants.

Until they receive full citizenship, neither undocumented immigrants nor RPIs will gain access to health care under the ACA as it is written today. They will be exempt from the mandatory fee imposed on uninsured citizens, and they will be unable to purchase health care insurance.

Texas and the Medicaid Expansion- The ACA can be expected to have several direct and indirect effects in Texas. Although Texas has declined Medicaid expansion, ramifications from the bill will still be present as federal insurance subsidies and the insurance trading market will be available to Texas residents. The ACA also calls for decreased reimbursements to disproportionate share hospitals (DSHs) under the assumption that most persons will be insured. In theory, this would reduce money available to care for undocumented immigrants and possibly place DSH (safety net hospitals) at jeopardy for hospital shutdown or withdrawal of certain services. Texas, with its large undocumented immigrant population and nonrecognition of PRUCOL status, is likely to feel these changes more than other states.

Undocumented Immigrants and Emergent Dialysis- All patients with ESRD require dialysis treatments to cleanse the blood of toxins and remove excess salt and water. Dialysis is either done every day by the patient at home (peritoneal dialysis) or in a center 3 times a week (hemodialysis). All dialysis patients, particularly those who are younger and healthier, are encouraged to be listed for a kidney transplant. In 1973, Congress enacted a historic legislation guaranteeing federal or state funding for all US citizens diagnosed with ESRD to defray the high cost of this treatment. The cost of hemodialysis today is estimated at $87,000 per person annually.

Undocumented immigrants with ESRD represent a population at the crux of immigration reform, health care reform, and the rising cost of chronic illnesses. EMTALA specified that an undocumented immigrant with ESRD who is medically unstable and presents to a hospital emergency room in need of emergent dialysis must be stabilized. Interpretation of EMTALA has led many hospitals, including safety net hospitals, to practice “emergent dialysis.” In emergent dialysis, the patient is first evaluated in the emergency room and then only receives treatment if a life-threatening indication is present. Typical indications include shortness of breath (pulmonary edema), feeling poorly (uremia), or a high potassium level (hyperkalemia). This is in contrast to scheduled dialysis, which happens regularly.

Emergent dialysis is 3.7 times more expensive per patient due to the associated costs of emergency room care (laboratory draws, studies, and physician fees) and more frequent patient hospitalizations as a result of poor health.9 Despite this high cost, this practice has been the standard of care because of the perceived notion that offering scheduled dialysis to undocumented immigrants could trigger an influx of immigrants with ESRD to the state. In the past decade, individual counties or cities have devised unique solutions to this problem.  For example, all patients in San Antonio receive scheduled dialysis, paid for by the county hospital system via contract to local for-profit dialysis centers; in Dallas, patients only receive emergent dialysis. In Houston, all patients begin with emergent dialysis, but one county-funded and county-operated dialysis center accepts emergent dialysis patients when space becomes available. The figures show this variability in care across these three cities in Texas. This same variability in dialysis options exists across the United States for this population.

More than 400,000 US citizens receive dialysis. Through extrapolation of published incident rates, experts estimate that 6000 undocumented immigrants in the United States require dialysis.10 From personal communication, we estimate that more than 1000 undocumented residents in Texas require dialysis. Given the high cost of dialysis and the even higher cost of emergent dialysis, Texas taxpayers are likely paying more than $10 million to manage these patients.

Emergent dialysis is not just more costly but also forces physicians into making difficult ethical decisions, such as deciding “which patient should receive treatment.” It is also associated with worse patient outcomes; the patient suffers physically from infrequent dialysis and financially from lost wages secondary to an inability to work around an irregular dialysis schedule.

Conclusion-Texas has a large, growing population of undocumented immigrants. Providing comprehensive health care to this population is a challenge, and these patients rely on safety net hospital systems. Legislation from 1986 to 2013 has made it increasingly difficult for these persons with chronic illnesses to receive cost-effective, adequate care. Undocumented immigrants with ESRD receive dialysis in Texas primarily when it becomes an emergent condition. While future RPI status may grant undocumented immigrants legality, the ACA specifies that this does not grant access to health care. With a growing undocumented immigrant population in Texas, our state legislators must be aware of and address this problem before it evolves into a health care crisis.

So, we have to learn from the European experience that if we as a country decide that we are responsible for all the undocumented illegal immigrants we need to find a way to pay for the increasing expense of allowing the immigrants to enter our country illegally.