“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence…..”

“The president promised two months ago that his administration would “spend a lot of time, a lot of effort and a lot of money on the opioid crisis.”
Sens. Elizabeth Warren (D-Mass.) and Lisa Murkowski (R-Alaska) are pushing President Donald Trump to formally declare the opioid epidemic a national emergency, something he promised in August but has yet to do.
It’s been 63 days since Trump verbally referred to the opioid crisis as a “national emergency,” the senators noted in a letter they sent to the president Thursday.
“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency. It’s a national emergency,” Trump told reporters while at his golf club in Bedminster, New Jersey. He said his administration was “drawing documents now” and planned “to spend a lot of time, a lot of effort and a lot of money on the opioid crisis.”
Declaring the national emergency would allocate more federal funding to state and local officials dealing with the crisis, as well as pressure lawmakers to take more long-term steps. But no documents have been filed, and the administration hasn’t said when Trump will make an official declaration.
White House press secretary Sarah Huckabee Sanders said in September that the delay was due to “a much more involved process,” and cited legal and administrative issues.” (A)

“New Jersey Gov. Chris Christie said Tuesday President Trump’s failure to officially declare the opioid crisis a national emergency was “not good,” according to a report.
“I think the problem is too big to say that if he had declared an emergency two months ago that it would make a significant difference in two months,” Christie said, per the Associated Press. “But I would also say you can’t get those two months back. And so it’s not good that it hasn’t been done yet.”
The two-term Republican governor chairs Trump’s Commission on Combating Drug Addiction and the Opioid Crisis, which was established in March via an executive order to specifically tackling the opioid epidemic that the body estimates claims about 142 Americans every day.
When asked about the delay, Christie said he had been told by the White House that there were “legal” issues involved with making such a declaration since it was not a natural disaster and had no firm end date.
Christie, however, added that the inaction had “lessened” the commission’s work as one of the key recommendations it made in a July draft report was to name the problem a national emergency.” (B)

“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.
The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.
Drugmakers, pharmaceutical distributors, pharmacies and doctors have come under intense scrutiny in recent years, but the role that insurers — and the pharmacy benefit managers that run their drug plans — have played in the opioid crisis has received less attention. That may be changing, however. The New York State attorney general’s office sent letters last week to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.
ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.
In contrast, almost every plan covered common opioids and very few required any prior approval.
The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.” (C)

“Nationally, according to the Centers for Disease Control and Prevention (CDC), a baby is born suffering from opioid withdrawal every 25 minutes.
Dayton Children’s Hospital has a program for such babies — a result of the mother using drugs like heroin or other opioids, like painkillers or fentanyl, while pregnant. The hospital’s neonatal intensive care unit treats 20 to 30 babies a year with an average stay of 17 days, down from 58 in 2012. In a hospital where the norm was once broken bones and the flu, the impact of the opioid epidemic is felt in every corner.
Ashley Hudson’s 12-day-old daughter A’Layjah was undergoing treatment at Dayton’s neonatal ICU in September. Her newborn son passed away last year, and she blames her drug use. “I can’t live through that again,” Hudson said.
Hudson said she stopped using heroin during this pregnancy but was treated with a maintenance drug that left A’Layjah born dependent. The unit was helping to treat the baby girl with both medicine and nonpharmacological measures — including low lighting and skin-to-skin bonding — and doctors said her prognosis was good.
For those infants born dependent on opioids, there’s a follow-up clinic, or developmental pediatrics program, where Jude Seidler, a precocious 2-year-old, was making his presence known one day last month.
Jude’s mother had used heroin every day of her pregnancy, and at nine days old, he went home with adoptive parents, Jay and Ashley Seidler. Dayton Children’s Hospital, they say, has been their lifeline.
“We’ve been able to chart his progress,” Jay Seidler said.” (D)

The data show that the situation is dire and getting worse. Until opioids are prescribed more cautiously and until effective opioid addiction treatment becomes easier to access, overdose deaths will likely remain at record high levels.
The opioid epidemic in 6 charts, by ANDREW KOLODNY, https://www.cbsnews.com/news/opioid-epidemic-in-6-charts/

“The national opioid crisis is a dilemma of dichotomies. There are challenges with both prescription and illicit drugs. The solutions must consist of efforts that realistically can reduce the number of people who become addicts in the first place, as well as cure those who do. The underlying issue of pain management can, in many cases, be addressed without drugs or certainly with less addictive formulations. There are public health challenges of both improving the treatment of pain and at the same time reducing the potential for addiction. Clearly, there are choices that can be made for suffering patients that are proven to be effective without the high risks associated with the powerful prescription opioids available today.
For all these issues, data specialists in the medical field can and must become key participants in our solutions effort. These data intelligence engineers can lead the development of fact-based plans of action that are capable of producing real change — change that results from the development of sophisticated data mining and pattern-matching algorithms that target factors associated with addiction. These algorithms can speed up the evaluation and viability of strategies that focus on reducing the death rate immediately and lowering the number of potential addicts in the future. It’s a huge task, but one that a new generation of data analytics tools can handle.” (E)

“The University of Pittsburgh’s Program Evaluation and Research Unit (PERU) is working with Pennsylvania officials to standardize death data from overdose victims.
“It’s represented by age, by gender, by ethnicity, by location,” Dr. Janice Pringle, PERU director, told Fox News.
The purpose of the project, Overdose Free PA, is to provide more detailed reporting in real-time that could help show where the problem areas are, Pringle said. Previously, each coroner’s office had a unique way of recording data on overdose victims, but the project provides them with a template for a standardized option of data reporting.
“That helps you understand that in certain parts of the state there may be patterns,” she told Fox News.
The data is also divided by the type of overdose death, including drugs that are not opioids, like cocaine and LSD, according to the website.
In 2016, there were 4,652 drug overdose deaths in the state, according to a Drug Enforcement Administration report. That equates to roughly 13 drug-related deaths per day.
Specifically, the study found the presence of an opioid, either illicit or prescribed by a doctor, in 85 percent of drug-related overdose deaths in the Keystone State.
Pringle said they’ve already seen the program’s impact in some areas.
“We do have a couple of counties in Pennsylvania that are stabilizing with their overdose rates,” she said.” “(F)

“The headlines from the opioid epidemic seem to be all about overdoses in public parks, homes, and elsewhere in the community. But the drugs can cause problems even in a setting where patients are under the direct care of doctors and nurses: the hospital.
Among the most common trouble spots:
Administration. These events included cases in which patients were given the wrong type of medication, such as a fast-release drug when the slow-release version was indicated. They also included events with the wrong frequency or dose of a drug, incorrect or omitted documentation, administration of opioids without an order, or inadequate patient assessment at administration.
Diversion. These cases include those in which opioids were “unsecured” or where the amount on the shelf did not match records. They also included removal of opioids without documentation that were given to a patient and the failure to account for disposal of leftover drugs.
Prescribing. Problems included prescribing more than one drug at a time or the wrong dose of a drug, and filling duplicate orders of drugs.” (G)

“Families across the United States are demanding that more be done to end the despair and devastation of addiction. Here are eight steps to take — now. They include some of the recommendations of the president’s commission….
SAVE LIVES Active users need to be kept alive long enough to seek treatment…
TREAT, DON’T ARREST Nearly 300 law enforcement agencies..participate in the Police Assisted Addiction and Recovery Initiative, which offers treatment for drug users who ask the authorities for help…
FUND TREATMENT Repealing Obamacare would eliminate Medicaid-funded treatment for thousands of addicts…
COMBAT STIGMA Misunderstanding of opioid addiction shrouds nearly every effort to reduce its toll…
SUPPORT MEDICATION-ASSISTED TREATMENT One of the most effective methods of treating drug addiction is through continuing medication therapies like methadone, naltrexone and buprenorphine…
ENFORCE MENTAL HEALTH PARITY Half to 70 percent of people with substance abuse problems also suffer from depression, post-traumatic stress or other mental health disorders…
TEACH PAIN MANAGEMENT The opioid crisis is rooted in our health care system: American physicians prescribe opioids for pain management at far higher rates than physicians prescribe them in any other nation.
START YOUNG WITH PREVENTION A 2015 study by the National Institute on Drug Abuse found that “Life Skills Training” for seventh graders helped them avoid misusing prescription opioids throughout their teenage years…. “(H)

“CVS is rolling out a series of changes aimed at addressing the nation’s opioid crisis.
The retailer announced that it will impose a seven-day limit on the supply of opioids dispensed for certain prescriptions and will also limit the daily dosage of certain opioids.
When a patient receives an opioid prescription, pharmacists will first discuss the risks of dependence and answer any questions the patient may have.” (I)

“Google implemented new restrictions on advertising related to searches for addiction treatment after “misleading experiences” involving treatment centers, a company spokeswoman said. Credit Dominick
As drug addiction soars in the United States, a booming business of rehab centers has sprung up to treat the problem. And when drug addicts and their families search for help, they often turn to Google.
But prosecutors and health advocates have warned that many online searches are leading addicts to click on ads for rehab centers that are unfit to help them or, in some cases, endangering their lives.
This week, Google acknowledged the problem — and started restricting ads that come up when someone searches for addiction treatment on its site. “We found a number of misleading experiences among rehabilitation treatment centers that led to our decision,” Google spokeswoman Elisa Greene said in a statement on Thursday.” (J)

“State attorneys general battling the opioid crisis have turned their attention to health insurance companies and “unnecessary overprescription” of the class of painkillers. The letter urged payers to take action, though it didn’t acknowledge the many steps insurers have already taken.
The National Association of Attorneys General (NAAG) sent a letter America’s Health Insurance Plans, asking its members to “review payment and coverage policies and revise them, as needed, to encourage healthcare providers to choose alternatives to prescribing” opioids.
“When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective nonopioid alternatives, ranging from nonopioid medications such as nonsteroidal anti-inflammatory drugs to physical therapy, acupuncture, massage and chiropractic care,” the NAAG letter (PDF), signed by 37 state and territorial attorneys general, argued.” (K)

“A local hospital group has developed a program that helps patients get alternative treatments for chronic pain besides prescription opioids, helping the network decrease its opiate use by 20 percent since it started implementing the steps in 2013.
The opioid overdose crisis has been in part connected to over-prescription of high power painkillers, and the KetteringHealth Network said at a Monday press conference that its goal with its new program, called “Pause,” is to get providers and patients to pause and consider alternatives to prescriptions that patients may become addicted to.
As the region’s opioid crisis intensified through the first half of this year, Montgomery County hospital emergency departments received 2,565 overdose patients — more than any other Ohio county. In all, Ohio emergency departments treated 19,128 overdoses during the period, including 2,204 in Cuyahoga County, the state’s most populous.
The state also has guidelines for treatment of chronic pain. Ohio Mental Health & Addiction Services’ guidelines encourage providers to assess whether they are in compliance with prevailing standards of care. The guidelines also ask providers to look into non-opioid therapy options and avoid long term prescribing opioids.” (L)

“A new University of Michigan initiative aiming to address societal health problems will begin with the opioid crisis, President Mark Schlissel announced Tuesday, Oct. 3…..
Michigan health-care providers wrote 11 million prescriptions for opioid drugs in 2015 and another 11 million in 2016, compared to roughly 8 million prescriptions in 2009. That equates to about 1.1 prescriptions for every Michigan residents, according to the state’s drug monitoring system.
“When patients undergo surgery and get an opioid prescription, some achieve good pain control using the prescribed dose, but many others don’t. And some become addicted,” Schlissel said. “Most new chronic users receive their first opioid prescription for post-surgical care, and 6 percent of patients who have never had an opioid before will become dependent long after surgery. Some patients don’t take their full dose, meaning unused pills can end up in the wrong hands.”
Schlissel said the project will examine ways health professionals can predict how much pain medication someone will need, based on their individual genetic profile, physiological condition and social, environmental and lifestyle factors, tailoring how they help individual patients manage pain.” (M)

“Cigna says it won’t cover prescriptions for the brand OxyContin for most customers starting next year — it’ll be taken off group preferred commercial drug lists.
In 2016, Cigna laid out a three-year plan to cut down on opioid use among its customers by a quarter. It seems this move is an effort to help meet that goal.
There are a few caveats to this announcement: Cigna will still cover at least one oxycodone alternative, and people who use OxyContin for hospice or cancer care will have their prescriptions covered. The company also says it’ll consider approving OxyContin if a customer’s doctor deems it medically necessary.
Cigna is notifying patients with current OxyContin prescriptions and their doctors about the future change.
“While drug companies don’t control prescriptions, they can help influence patient and doctor conversations by educating people about their medications. The insights we obtain from the metrics in the new value-based contract will help us continue to evolve our opioid management strategies to assist our customers and their doctors,” Jon Maesner, Cigna’s chief pharmacy officer, said.” (N)

“Wisdom teeth surgery involves pliers, so there’s often some post-operative pain. For years, dentists have prescribed painkilling opioids, like percocet or vicodin for patients.
But with opioid abuse claiming lives in Colorado and across the country, oral surgeons and other health care providers are looking to alternatives. Lafayette oral surgeon Curt Hayes recently switched to FDA-approved local anesthetic Exparel, a non-opioid. When he injects it into his patient’s’ gums the area will stay numb and pain free for two to three days.
He can now generally remove wisdom teeth without using any narcotics for pain — so there’s no need to prescribe his patient a dozen or more pills.
“I’ve backed off to where I don’t give any narcotics whatsoever,” said Hayes. “I have people just using ibuprofen and then over-the-counter Tylenol, and that’s acceptable. And it takes care of the pain.”
Hayes followed the development of Exparel, also known by its generic name bupivacaine, in journals. Other doctors started using it for C-Sections. He started using it mainly for patients who had abused narcotics in the past, to avoid relapses. After seeing positive results, Hayes started making it an option for all his patients….
Colorado’s dental board is developing new best practices and the Colorado Dental Association is holding educational seminars. Dr. Brett Kessler, a dentist in Denver and past president of the state association, said across the board, medical providers are re-examining their role in the opioid crisis.
“It’s on every health care practitioner’s mind,” Kessler said. “Looking for alternatives to manage the pain is huge, and it’s a growing trend nationally.” “(O)

“How to help someone with an opioid problem
The state’s Next Level Recovery website suggests watching for these seven signs that you or someone you care about might have an opioid-use disorder:
• Needing higher doses of the opioid to get the same effect that a lower dose used to provide.
• Trying to quit more than once without having success.
• Thinking about getting high as soon as you wake up in the morning.
• Getting anxious or agitated within several hours of your last dose.
• Experiencing vomiting, diarrhea or nausea after quitting for a short period of time.
• Having less interest in activities you used to enjoy.
• Using opioids when driving or caring for children.” (P)

“In the state morgue here, in the industrial maze of a hospital basement, Dr. Thomas A. Andrew was slicing through the lung of a 36-year-old woman when white foam seeped out onto the autopsy table.
Foam in the lungs is a sign of acute intoxication caused by an opioid. So is a swollen brain, which she also had. But Dr. Andrew, the chief medical examiner of New Hampshire, would not be certain of the cause of death until he could rule out other causes, like a brain aneurysm or foul play, and until after the woman’s blood tests had come back….
After laboring here as the chief forensic pathologist for two decades, exploring the mysteries of the dead, he retired last month to explore the mysteries of the soul. In a sharp career turn, he is entering a seminary program to pursue a divinity degree, and ultimately plans to minister to young people to stay away from drugs.” (Q)

(A) Elizabeth Warren, Lisa Murkowski Push Trump To Declare Opioid Crisis A National Emergency, by By Paige Lavender, https://www.huffingtonpost.com/entry/warren-murkowski-opioids_us_59df88b9e4b00abf3646f4dc
(B) Chris Christie: Trump’s delay in declaring the opioid crisis a national emergency is ‘not good’, by Naomi Lim, http://www.washingtonexaminer.com/chris-christie-trumps-delay-in-declaring-the-opioid-crisis-a-national-emergency-is-not-good/article/2637108
(C) Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers, by KATIE THOMAS and CHARLES ORNSTEIN, https://www.nytimes.com/2017/09/17/health/opioid-painkillers-insurance-companies.html
(D) A Generation at Risk: Children at Center of America’s Opioid Crisis,by DANIEL A. MEDINA, KATE SNOW, ML FLYNN and ERIC SALZMAN, https://www.nbcnews.com/storyline/americas-heroin-epidemic/generation-risk-children-center-america-s-opioid-crisis-n806456
(E) Using Big Data Medical Analytics To Address The Opioid Crisis, John Kelley, https://www.forbes.com/sites/forbestechcouncil/2017/10/02/using-big-data-medical-analytics-to-address-the-opioid-crisis/#18c0e84c142c
(F) Opioid crisis: Researchers employ new method to track overdose victims, by Michelle Chavez, http://www.foxnews.com/health/2017/10/10/opioid-crisis-researchers-employ-new-method-to-track-overdose-victims.html
(G) Even in hospitals, opioids can cause harm, by Tom Avril, http://www.philly.com/philly/health/addiction/opioid-overdose-in-hospital-medication-error-narcan-20171016.html
(H) America’s 8-Step Program for Opioid Addiction, https://www.nytimes.com/2017/09/30/opinion/opioid-addiction-treatment-program.html?mcubz=0
(I) CVS is taking steps to address the nation’s opioid crisis, http://abc13.com/health/cvs-imposes-opioid-limits-to-address-nations-crisis/2441143/
(J) Google Sets Limits on Addiction Treatment Ads, Citing Safety, by By MICHAEL CORKERY, https://www.nytimes.com/2017/09/14/business/google-addiction-treatment-ads.html?_r=0
(K) State AGs push health insurers to rein in opioid prescriptions, fail to acknowledge they’re already doing so, by Gienna Shaw, http://www.fiercehealthcare.com/payer/how-do-health-insurance-companies-control-opioid-abuse
(L) Hospital program attempts to reduce opioid use in patients, Kaitlin Schroeder, http://www.daytondailynews.com/news/local/hospital-program-attempts-reduce-opioid-use-patients/m61zU9FMvhQL1mWzEZ1NxI/
(M) University of Michigan tackling opioid crisis in new health initiative, by Martin Slagter , http://www.mlive.com/news/ann-arbor/index.ssf/2017/10/university_of_michigan_tacklin.html
(N) A top health insurance company is joining the fight against the opioid epidemic., by Cristina Mutchler, http://www.wtmj.com/newsy/health-insurer-drops-oxycontin-coverage-to-fight-opioid-crisis
(O) Colorado Dentists And Other Docs Seek Opioid Alternatives As Crisis Worsens, by John Daley, http://www.cpr.org/news/story/colorado-dentists-and-other-docs-seek-opioid-alternatives-as-crisis-worsens
(P) How to help someone with an opioid problem, by Jenny Ung and Jennifer Morlan, https://www.usatoday.com/story/news/nation-now/2017/10/08/how-help-someone-opioid-problem/745046001/
(Q) As Overdose Deaths Pile Up, a Medical Examiner Quits the Morgue, by KATHARINE Q. SEELYE, https://www.nytimes.com/2017/10/07/us/drug-overdose-medical-examiner.html?_r=0

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“… President Donald Trump on Wednesday backed away from a bipartisan deal on healthcare reached by two senators…

a day earlier, saying he could never support legislation “bailing out” insurance companies.
On Tuesday, Trump appeared to embrace the deal struck by Republican Senator Lamar Alexander and Democratic Senator Patty Murray as “a short-term solution so that we don’t have this very dangerous little period,” apparently referring to possible premium spikes in the wake of his recent decision to cut off subsidy payments to insurance companies.
But in a tweet on Wednesday he took a different tack on the bill, which would continue the cost-sharing subsidies that lower premiums for lower-income Americans, writing: “I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co’s who have made a fortune w/ O’Care.” (A)

“A proposal in the Senate to help stabilize Affordable Care Act marketplaces would ensure that subsidies paid to insurance companies benefit consumers rather than padding the companies’ profits.
A draft of the bill, obtained by NPR, requires health plans to offer the subsidies as one-time or monthly rebates to consumers or they will be repaid to the federal government. The subsidies, known as cost-sharing reduction payments, are designed to reimburse insurance companies for discounts they are required to offer their customers on copayments and deductibles. President Trump has criticized the payments as a “bailout” and said last week he would cut them off.” (B)

“Sens. Lamar Alexander and Patty Murray have reached a deal “in principle” to restore Affordable Care Act cost-sharing reduction payments for two years in exchange for more state flexibility in Obamacare.
One Senate aide said the plan would also restore just over $100 million in funding for Obamacare outreach, which is particularly critical since the Trump administration has slashed support for 2018 open enrollment, which begins on November 1.
An Alexander aide told CNN that Republicans would get a provision they wanted, a major change in how states measure the affordability of insurance under their waiver requests. This would allow states a lot more flexibility, but that final language was still being ironed out.
The deal would make it easier for states to obtain waivers to customize Obamacare rules to their needs. States have complained that applying for waivers is a long and complicated process. Alaska and Minnesota, for instance, have received permission to use federal funds for reinsurance programs that reduce premiums. This agreement would speed administration approval of the waivers and allow states to copy provisions in waivers that were already approved.
However, it does not actually loosen any of Obamacare’s regulations, which had been a key goal of the Republican effort to repeal the health reform law.
The agreement would also allow all Obamacare enrollees to sign up for so-called catastrophic plans, which have lower premiums but have higher deductibles. Right now, these so-called copper policies are only open to those under 30.
There are no guarantees that Republican leadership would bring such a plan to the floor without significant support from rank-and-file members. Getting a sizable number of co-sponsors will be key to the Murray and Alexander’s success. That work has yet to begin. “ (C)

“A bipartisan Senate deal that would extend critical ObamaCare payments to insurers for two years got the cold shoulder from Republicans on Tuesday, suggesting it faces a rocky path to become law.
The chairman of the conservative Republican Study Committee in the House dismissed the offering from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) as an affront to GOP promises to repeal President Obama’s signature legislation.
“Anything propping [ObamaCare] up is only saving what Republicans promised to dismantle,” said Rep. Mark Walker (R-N.C.), who leads a group of more than 150 conservatives.
Senate Majority Leader Mitch McConnell (R-Ky.) stopped short of promising to bring the bill to the floor, and while Sens. John McCain (R-Ariz.) and Susan Collins (R-Maine) offered some praise, not a single Senate GOP conservative offered strong public support for the compromise.
Senate Democrats, in contrast, hailed the deal, and pressed GOP leaders to quickly bring it to the floor.” (D)

Hospitals should see rising bad debt in 2018 as these co-pays/deductibles go unfunded
Without CSRs, insurers say, Obamacare patients will see costs jump 25% or more in 2018
The nation’s doctors and hospitals are bracing for an increase in unpaid medical bills after President Donald Trump’s decision on Friday to stop funding subsidies that low-income Americans use to pay their out-of-pocket costs.
Trump’s decision comes just before the beginning of open enrollment on Nov. 1 for subsidized individual coverage sold on public exchanges for 2018 under the Affordable Care Act. Cost-sharing reductions (CSRs) help purchasers of subsidized silver plans pay their co-payments and deductibles…
Trump’s move also comes with Americans, beyond just those in Obamacare plans, already seeing a jump in their out-of-pocket healthcare costs. Employee benefits consultancy Aon says out-of-pocket costs for workers at large employers will, for the first time in 2018, eclipse $2,500, and that trend has impacted providers.” (E)

“As a candidate, Donald Trump sold himself as a deal maker. As president, he’s governing more as a hostage taker.
Across an array of domestic and foreign challenges, Trump’s go-to move has become to create what amounts to a political hostage situation. He’s either terminating, or threatening to terminate, a series of domestic and international policies adopted by earlier administrations — and insisting that others grant him concessions to change his mind….
Trump’s expectation is that his threats will strengthen his leverage over whoever he’s negotiating against — whether Democrats in Congress, foreign governments, or both. But the early experience suggests that Trump’s actions more often may have the opposite effects: to isolate him, divide his allies, and harden opposition to his proposals.
Trump’s threats to undo major agreements have unquestionably heightened anxiety and created disruption for those he’s trying to pressure.
Just the possibility that Trump would end the cost-sharing payments, which reimburse insurance companies for limiting out-of-pocket health care costs for low income consumers, already forced insurers to preemptively raise premiums this year, adding more pressure on Obamacare markets. His move to actually stop the payments could make coverage unaffordable for many more of the uninsured and/or prompt insurance companies to flee more states under the ACA.” (F)

“Now, in reality, the Obama administration was highly selective in enforcing the Affordable Care Act as written. Here are just some examples of ways in which Obama simply ignored the Affordable Care Act and decided to do what he thought was best, regardless of the law:
The Obama administration decided not to enforce the law’s employer mandate until 2015, and then delayed its enforcement a second time.
After millions of Americans complained that their insurance plans had been canceled—contrary to Obama’s promise that “if you like your plan, you can keep your plan”—Obama declined to enforce aspects of the law that required those plans to shut down—until he was reelected.
The Obama administration decided—unilaterally—to waive Obamacare’s individual mandate, by granting a “hardship exemption” to anyone for whom Obamacare’s offerings were “unaffordable.”
The Affordable Care Act forced insurers to offer plans with reduced co-pays and deductibles for those with very low-incomes, but didn’t appropriate the cost-sharing subsidies needed to pay for them. Facing a rebellion from insurers, who were being forced to cover these individuals at a loss, the Obama administration decided to spend the money anyway, even though they had no legal authority to do so.” (G)

(A) Trump Backs Away From Bipartisan Senate Healthcare Bill, by Tim Ahmann, https://www.usnews.com/news/top-news/articles/2017-10-18/trump-backs-away-from-bipartisan-senate-healthcare-bill
(B) Draft Of Health Care Bill Addresses Trump Concerns About ‘Bailouts’ For Insurers, by Alison Kodjak, http://www.npr.org/2017/10/18/558546804/draft-of-health-care-bill-addresses-trump-concerns-about-bailouts-for-insurers
(C) Bipartisan senators reach small deal on health care, by Lauren Fox and Tami Luhby, http://www.cnn.com/2017/10/17/politics/health-care-csr-payments-deal-reached/index.html
(D) New health deal falls flat with GOP, by PETER SULLIVAN, http://thehill.com/policy/healthcare/355917-new-health-deal-falls-flat-with-gop
(E) Hospitals Brace For Unpaid Patient Bills After Trump Ends Obamacare Subsidies, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/15/hospitals-brace-for-unpaid-patient-bills-after-trump-ends-obamacare-subsidies/#f1ee9b251f8d
(F) How Donald Trump is negotiating like a hostage-taker, by Ronald Brownstein, http://www.cnn.com/2017/10/17/politics/donald-trump-negotiating-strategy/index.html
(G) Sorry Everbody, But Trump Hasn’t Instigated The Obamacare Apocalypse, by Avik Roy, https://www.forbes.com/sites/theapothecary/2017/10/14/sorry-everbody-but-trump-hasnt-instigated-the-obamacare-apocalypse/#219155ae7099

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Congress blocked DEA action against drug companies suspected of flooding the country with prescription narcotics

“In April 2016, at the height of the deadliest drug epidemic in U.S. history, Congress effectively stripped the Drug Enforcement Administration of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets…
A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills, according to an investigation by The Washington Post and “60 Minutes.” The DEA had opposed the effort for years.
The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns…
For years, some drug distributors were fined for repeatedly ignoring warnings from the DEA to shut down suspicious sales of hundreds of millions of pills, while they racked up billions of dollars in sales.
The new law makes it virtually impossible for the DEA to freeze suspicious narcotic shipments from the companies, according to internal agency and Justice Department documents and an independent assessment by the DEA’s chief administrative law judge in a soon-to-be-published law review article. That powerful tool had allowed the agency to immediately prevent drugs from reaching the street.” (A)

“President Donald Trump said Monday that “we’re going to be looking into” Rep. Tom Marino, the White House’s pick to be the nation’s next drug czar, after CBS’ “60 Minutes” and The Washington Post reported that the lawmaker championed a law that hobbled federal efforts to combat the abuse of opioids….
According to reporting by the Post and “60 Minutes,” Marino was the top lawmaker championing the Ensuring Patient Access and Effective Drug Enforcement Act, legislation that the news outlets said makes it essentially impossible for the Drug Enforcement Administration to freeze suspicious narcotics shipments from drug companies. The DEA had fought against the bill, while the pharmaceutical industry lobbied hard on its behalf.” (B)

“Republican members of Congress Tom Marino of Pennsylvania and Marsha Blackburn of Tennessee promoted the bill as a way to ensure that patients had access to the medication they needed…
“…. the argument that made the bill unanimously pass Congress was that “legitimate painkiller users were not getting their drugs in an efficient manner.”
“There’s nothing in the law that actually changes that at all,” Bernstein said during a conversation on “CBS This Morning.” “The evidence for that was actually sort of anecdotal. Whereas the evidence for the fact that these pills were ending up in the hands of dealers and users was quite substantial.”
Asked whether he feels as though these drug distributors are complicit in the opioid crisis, Bernstein responded, “Well, they certainly have been caught numerous times over, and over and over again, not reporting suspicious orders of these opioid pain pills from doctors and pharmacies.”” (C)

“Rep. Tom Marino, R-Pa., has withdrawn his name from consideration as America’s drug czar, President Trump said Tuesday. Marino is stepping back days after reports that legislation he sponsored hindered the Drug Enforcement Administration in its fight against the U.S. opioid crisis…
Marino was a main backer of the Ensuring Patient Access and Effective Drug Enforcement Act; among other things, the measure changed the standard for identifying dangers to local communities, from “imminent” threats to “immediate” threats. That change cramped the DEA’s authority to go after drug companies that didn’t report suspicious — and often very large — orders for narcotics.
Sen. Joe Manchin, D-W.Va., said he was “horrified” by the story, adding that he “cannot believe the last administration did not sound the alarm on how harmful that bill would be for our efforts to effectively fight the opioid epidemic.”
In a letter to the president, Manchin wrote about the ability of wholesale drug distributors to send millions of pills into small communities:
“As the report notes, one such company shipped 20 million doses of oxycodone and hydrocodone to pharmacies in West Virginia between 2007 and 2012. This included 11 million doses in one small county with only 25,000 people in the southern part of the state: Mingo County. As the number of pills in my state increased, so did the death toll in our communities, including Mingo County.”..
Manchin has co-sponsored legislation that would repeal the changes made by the 2016 law, along with Sen. Claire McCaskill, D-Mo., and Sen. Margaret Wood Hassan, D-N.H. “ (D)

“Mr. Marino’s withdrawal leaves three of the major federal agencies responsible for managing the opioid crisis—the White House drug-control office, the Department of Health and Human Services and the DEA—with no nominees to head them. Mr. Trump’s national opioid commission, led by New Jersey Gov. Chris Christie, is expected to release a final report with recommendations next month.
During his news conference, Mr. Trump said that he would likely make a “major announcement” on the “drug crisis” next week.” (E)

(A) THE DRUG INDUSTRY’S TRIUMPH OVER THE DEA, by Scott Higham and Lenny Bernstein, https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/?utm_term=.76234a485f43
(B) Trump: ‘Looking into’ Marino’s nomination as drug czar after report on opioid legislation, by LOUIS NELSON, http://www.politico.com/story/2017/10/16/trump-tom-marino-drug-czar-opioid-legislation-243827
(C) Washington Post reporter on how Congress may have fueled America’s opioid crisis, by LAUREN MELTZER, https://www.cbsnews.com/news/opioid-epidemic-60-minutes-washington-post-investigation-lenny-bernstein/
(D) Tom Marino, Trump’s Pick As Drug Czar, Withdraws After Damaging Opioid Report, by Bill Chappell, http://www.npr.org/sections/thetwo-way/2017/10/17/558276546/tom-marino-trumps-pick-as-drug-czar-withdraws-after-damaging-opioid-report
(E) Trump’s Pick for Drug Czar, Tom Marino, Withdraws Name from Consideration, by Peter Nicholas, https://www.wsj.com/articles/donald-trumps-pick-for-drug-czar-tom-marino-withdraws-name-from-consideration-1508244954

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Trump vows to rip apart Obamacare piece by piece. (A)

“In a move likely to roil America’s insurance markets, President Donald Trump will “immediately” halt payments to insurers under the Obama-era health care law he has been trying to persuade Congress to unravel for months….
“…. the White House said the government cannot legally continue to pay the so-called cost-sharing subsidies because they lack a formal authorization by Congress. Officials said a legal opinion from the Justice Department supports that conclusion…
Experts have warned that cutting off the money would lead to a double-digit spike in premiums, on top of increases insurers already planned for next year. That would deliver another blow to markets around the country already fragile from insurers exiting and costs rising. Insurers, hospitals, doctors’ groups, state officials and the U.S. Chamber of Commerce have urged the administration to keep paying…
Consumers who receive tax credits under the ACA to pay their premiums would be shielded from those premium increases. But millions of others buy individual health care policies without any financial assistance from the government and could face prohibitive increases. Taxpayers would end up spending more to subsidize premiums.” (B)

“ “Massive subsidy payments to their pet insurance companies have stopped,” Trump said in a Tweet early Friday morning, alluding to the support of Democrats in Congress for CSRs.
But the CSRs are a pass-through from the government through the insurer and directly to the patient. Thus, a single-digit rate increase becomes a rate increase of 20%-25% without the CSRs, insurers have warned for months now.
“These payments are not a bailout – they are passed from the federal government through health plans to medical providers to help lower costs for patients who see a doctor to treat their cancer or fill a prescription for a life-saving medication,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association said in a joint statement Friday morning.
Most insurers, including Anthem, Oscar Health, Centene, Molina and Blue Cross and Blue Shield plans, will still make money if Americans buy their plans because customers will have to pay much higher rates thanks to Trump’s move. The end to CSRs, though, could prevent many from buying the policies in the first place or paying their out-of-pocket costs….” (C)

“The Trump administration is hinting that it will continue to enforce the ObamaCare mandate requiring Americans to have health insurance coverage. An administration document obtained by The Hill that accompanies an executive order signed by President Trump Thursday states that “only Congress can change the law” when it comes to the mandate.
“Will the Administration be enforcing the individual and employer mandates?” the question and answer document asks.
“While HHS has the ability to define a hardship exemption for the purpose of the individual mandate, the tax penalties are contained in the Internal Revenue Code and only Congress can change the law,” the document states in response, referring to the Department of Health and Human Services.
The statement leaves some room for creating more exemptions to enforcement of the mandate, noting that the administration can offer “hardship exemptions.” But it emphasizes that only Congress can change the law that mandates penalties for not having coverage…..” (D)

“The combined effect of cutting off the insurance payments and the executive order will be to destabilize the A.C.A.’s individual market, which is used by nine million people to buy health insurance. Younger and healthier people will be tempted to buy a skimpy short-term policy with low premiums and switch to a policy that complies with the A.C.A. only when they need medical care. Knowing that they will no longer receive cost-sharing payments and that Obamacare policies will tend to attract older and sicker people, insurers will probably jack up premiums or withdraw altogether in sparsely populated counties.
State governments, public interest groups and others will seek to prevent some of the damage from the order. There is some hope that they will be able to shape the regulations during the public comment period. If the final rules are still harmful, some groups will most likely file lawsuits….(E)

“White House Chief of Staff John Kelly told reporters that there probably won’t be a new Obamacare repeal bill until the spring and declined to join President Trump in attacking Senate Republican leadership…
“We probably won’t have a healthcare bill until the spring,” he said. “This was a way to take care of as many Americans as he could legally with an executive order.”…”Congress is designed to be extremely complicated, slow-moving part of our government,” he said. “I have nothing but respect for members of Congress and the staffs that work for them.” (F)

“In theory, precipitously ending the payments could lead to catastrophic market failures. Insurers set prices for their insurance this year, assuming the payments would continue to be made, and have no ability to raise them midyear to cover their losses. But, because the president has repeatedly signaled that the payments might cease and we are nearing the end of 2017, many plans set their prices for next year’s products assuming the subsidies would not be paid.
A few months ago, we called those increased prices an uncertainty tax. The uncertainty is gone now. But the conservative planning of the insurance industry means that many insurers can afford to keep offering insurance, even after the president cuts off the funding. Plans that priced for the threat will take a small haircut this year, but they can still make money, even without the payments, next year.” (G)

“Even before Mr. Trump’s decision, Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, were working on legislation to extend the subsidies, paired with other measures to offer states more flexibility regulating health plans offered under President Barack Obama’s health law.
But Republicans in Congress are divided. Some worry that ending the subsidies would hurt their constituents. Others are loath to do anything that could be seen as propping up the health law that they had promised to tear down.
For their part, Democrats are convinced that any blame for rising premiums and shrinking choices will fall on Republicans, who now control the White House and Congress. After spending the year trying to preserve the Affordable Care Act, Democrats did not appear ready on Friday to make major concessions.” (H)

“But there’s another question here, which is the electoral consequence. If health insurance gets worse, will people blame Barack Obama and the Democrats, or Donald Trump and the Republicans?” (I)

(A) Trump vows to rip apart Obamacare piece by piece, http://abcnews.go.com/WNT/video/trump-vows-rip-obamacare-piece-piece-50472671
(B) Trump to issue stop-payment order on health care subsidies, by ricardo alonso-zaldivar, http://abcnews.go.com/Health/wireStory/trump-halt-subsidies-health-insurers-50455624
(C) Trump’s Termination Of Obamacare Subsidies Hurts Patients, Not Insurers, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/13/trumps-end-to-subsidies-hurts-patients-not-insurers/#525cb1444c61
(D) Trump administration hints at enforcing ObamaCare mandate, BY PETER SULLIVAN, http://thehill.com/policy/healthcare/355144-trump-administration-hints-at-enforcing-obamacare-mandate
(E) Congress Can’t Let Mr. Trump Kill Obamacare on His Own, https://www.nytimes.com/2017/10/12/opinion/editorials/congress-cant-let-mr-trump-undo-obamacare-on-his-own.html?_r=0
(F) John Kelly: Obamacare repeal effort likely to return in spring, by Robert King, http://www.washingtonexaminer.com/john-kelly-obamacare-repeal-effort-likely-to-return-in-spring/article/2637332
(G) Trump Is Trying to Gut Obamacare. Here’s Why His Plan May Fail, by Margot Sanger-Katz, https://www.nytimes.com/2017/10/13/upshot/trump-is-telling-obamacare-insurers-he-doesnt-support-the-market.html
(H) End to Health Care Subsidies Puts Congress in a Tight Spot, By THOMAS KAPLAN and ROBERT PEAR, https://www.nytimes.com/2017/10/13/us/politics/trump-congress-obamacare-insurance-subsidies.html
(I) Trump’s Head-Scratching Health-Care Moves, by Jonathan Bernstein, https://www.bloomberg.com/view/articles/2017-10-13/trump-s-head-scratching-health-care-moves

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Trump’s Executive Order: “By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges.”

“President Donald Trump signed an executive order Thursday morning intended to allow small businesses and potentially individuals to buy a long-disputed type of health insurance that skirts state regulations and Affordable Care Act protections.
The White House and allies portray the president’s move to expand access to “association health plans” as wielding administrative powers to accomplish what congressional Republicans have failed to achieve: tearing down the law’s insurance marketplaces and letting some Americans buy skimpier coverage at lower prices. The order is Trump’s biggest step to carry out a broad but ill-defined directive he issued his first night in office for agencies to lessen ACA regulations from the Obama administration…
According to White House and agency officials, , the most far-reaching element of the multi-prong order instructs a trio of Cabinet departments to rewrite federal rules for association health plans – a type of insurance in which small businesses of a similar type band together through an association to negotiate health benefits.
The order will expand the availability of short-term insurance policies, which offer limited benefits meant as a bridge for people between jobs or young adults no longer eligible for their parents’ health plans. The Obama administration ruled that short-term insurance may not last for more than three months; Trump will extend that to nearly a year.” (A)

“In an effort to allow employers to form groups and obtain coverage across state lines, the order directs the administration to consider expanding Association Health Plans (AHPs), which allow small businesses in a similar sector or trade to band together to negotiate health benefits with other states.
This is a controversial measure and some experts predict there could be legal challenges, but supporters say it would increase competition by allowing employers to find the states offering the cheapest plans. It could also give more leverage to small businesses to negotiate policies. Additionally, the order calls for a broader interpretation of the Employee Retirement Income Security Act (ERISA), a law that regulates group plans provided by employers.
While ObamaCare mandated that short-term insurance policies should not last for more than three months, Trump is looking to expand those plans. The order says these short-term limited duration insurance (STLDI) offerings typically cost one-third of the price of the cheapest ObamaCare plans, while featuring broad provider networks and coverage. These plans are also not subject to most ObamaCare requirements…
The administration’s order also directs the government to look into ways to expand the use of Health Reimbursement Arrangements, or tax-free accounts that allow employers to reimburse employees for medical expenses. This measure is intended to give Americans greater control over their finance and health care.” (B)

“Although Mr. Trump has been telegraphing his intentions for more than a week, Democrats and some state regulators are now greeting the move with increasing alarm, calling it another attempt to undermine President Barack Obama’s signature health care law. They warn that by relaxing standards for so-called association health plans, Mr. Trump would create low-cost insurance options for the healthy, driving up costs for the sick and destabilizing insurance marketplaces created under the Affordable Care Act.
“It would have a very negative impact on the markets,” said Mike Kreidler, the insurance commissioner in Washington State. “Our state is a poster child of what can go wrong. Association health plans often shun the bad risks and stay with the good risks.”
They also worry that the Trump administration intends to loosen restrictions on short-term health insurance plans that do not satisfy requirements of the Affordable Care Act.
“By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges,” said Topher Spiro, a vice president of the Center for American Progress, a liberal research and advocacy group. “For older, sicker people left behind in plans regulated under the Affordable Care Act, premiums could increase.”” (C)

“Critics, however, worry that the order may free these association health plans from several key Obamacare regulations and from state oversight, allowing them to sell plans with lower premiums but skimpier benefits. That could draw younger and healthier customers away from Obamacare and send premiums skyrocketing for sicker people left in the exchanges.” (D)

“If Donald Trump signs an executive order as early as this week allowing insurance companies to be able to sell health plans across state lines, it’s unlikely to have any takers willing to prop up medical provider network in new regions.
The trend in insurance is to narrow – not expand – networks of doctors and hospitals.
“Insurance companies have not been very interested because we are moving to these network based plans,” Sabrina Corlette, professor with the Center on Health Insurance Reforms at Georgetown University said last week during a Commonwealth Fund briefing. “Since the 1990s, health insurance has evolved and has been a network driven product.”
It’s unclear exactly what will be in Trump’s executive order, which he mentioned within days after the failure of the latest Republican attempt to replace and replace the Affordable Care Act.
Health insurance companies in some states can already sell health coverage across state lines, but it hasn’t worked in large part because plans haven’t wanted to spend the money contracting with more doctors and hospitals in areas they have no enrollees. Six states have enacted laws allowing health plan sales across state lines and “no state was known to actually offer or sell such policies,” National Conference of State Legislatures said in a new report last week.
“In the states that have tried to do this, there has been zero interest from carriers,” Georgetown’s Corlette, who is also the consumer representative to the National Association of Insurance Commissioners.” (E)

We’re Tracking the Ways Trump Is Scaling Back Obamacare. Here Are 11.,
By HAEYOUN PARK ,, https://www.nytimes.com/interactive/2017/10/12/us/trump-undermine-obamacare.html


President Donald Trump’s executive order could take health care insurance away from millions of sick Americans, which was also a criticism of his earlier effort to repeal and replace the Affordable Care Act in Congress. The new plan would roll back some of Obamacare’s protections and coverage, but it could lower premiums for healthy Americans.

“Republicans in Congress should take President Donald Trump’s hint about working with Democrats on health care as motivation to follow through with their own promises, Mick Mulvaney, director of the White House Office of Management and Budget, said on Sunday’s “Meet The Press.”
Mulvaney’s comment comes on the heels of a Saturday morning tweet from Trump, stating: “I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!”
When asked what Republican lawmakers should take from that tease, Mulvaney responded, “Keep your promises.”
“The president wants to get something done,” he said. “He sees and understands what Obamacare is doing to folks back home, and he really doesn’t like it very much. So he’s looking for folks who will work with him to help change that. We had hoped it would be the Republicans in the Senate. They failed twice to do that. And can you blame the president then to sort of step back and say, ‘Okay, if my own party can’t deliver what I need, can I work with the other side?’ That’s not an unreasonable position.”” (F)

“Republican Sen. Ron Johnson said Sunday he believed Congress could reach an agreement on health care that includes continuing the funding of a key set of Obamacare subsidies to keep down insurance premiums.
The conservative Wisconsin senator said in an interview on CNN’s “State of the Union” that he understands some of his Republican colleagues are against funding the cost-sharing reduction — or CSR — payments. But he said the government should keep making the payments to prevent the cost of insurance skyrocketing.
President Trump has not committed to paying insurers the cost-sharing subsidies, which reduce deductibles and co-pays for low-income Obamacare enrollees. This has prompted many insurers to raise their premiums for 2018 to make up for the anticipated loss of the subsidies. The 2018 rates have already been finalized.
Johnson added that any such move to support continuing those payments would come with strings attached. “We should get something in return for that,” he said. For example, he said, Congress should make it so anyone has the option to purchase a “catastrophic plan” — insurance with relatively low premiums but high deductibles that provides fewer benefits. Johnson also said they should make health savings accounts more usable.” (G)

“Local and state groups that help with ObamaCare enrollment say they will likely have to reduce their services following funding cuts from the Trump administration.
Funding for the “navigator” groups, which provide outreach, education and enrollment assistance, was cut in half this year for being “ineffective,” Trump officials have said.
Now most of the navigator programs say they will have to limit their services this year, according to a new survey from the Kaiser Family Foundation (KFF).
Among programs that got reduced funding this year, 45 percent of statewide programs and two-thirds of regional programs said it is “somewhat or very likely” they will have to limit the territory their program will serve, according to the survey.
This could primarily impact consumers living in rural areas.
Some 55 percent of statewide navigator programs and 72 percent of regional programs expect to limit services to rural residents this year, KFF found. “ (H)

“New Jersey will lose more than 60 percent of the federal funding it expected to receive this year to help enroll vulnerable citizens in health insurance plans, a new report found, a change advocates fear will make it harder to reach those most in need of affordable care.
Officials at the federal Centers for Medicare and Medicaid Services announced more than $26 million in funding cuts in September that will impact the Affordable Care Act navigator programs in all but three states (Delaware, Kansas, and West Virginia); more than a dozen states lost at least half their funding.
New Jersey saw support drop to nearly $721,000 from the roughly $1.9 million received last year, according to a detailed analysis of these cuts released Wednesday by the nonprofit Kaiser Family Foundation. The money is distributed among five nonprofit programs that will see between 10 percent and 86 percent less funding this fall than they had to work with in 2016, the foundation determined.” (I)

What scares the members of Congress who for decades have collected hefty donations from the insurance and health-care industries and then used their positions of public trust to sustain and protect profiteering by those industries?
The threat of a single-payer “Medicare for All” health-care system.
By replacing the bureaucratic profiteers with an efficient system that would guarantee care for every American—and fair compensation for doctors and nurses—single payer would not merely make health care more accessible and more affordable. It would also make politics more honest and responsive to the will of the people.
House Speaker Paul Ryan has, through the campaign committees and political action committees that he guides, collected millions of dollars from Wall Street interests, insurance interests, pharmaceutical interests, private hospital and nursing home interests, and “health products” interests over the course of a political career that has seen him go to the mat, again and again, in defense of Wall Street interests, insurance interests, pharmaceutical interests, private hospital and nursing home interests, and “health products” interests.
So is it any surprise that Ryan keeps trying to “repeal and replace” the Affordable Care Act with measures that benefit his crony-capitalist campaign funders?
Single payer is a bad idea for senators whose political survival is based on banking checks from health-care profiteers. But it is a very good idea for America.” (J)

(A) Trump signs executive order to scale back Obamacare insurance rules, Amy Goldstein, http://www.chicagotribune.com/news/nationworld/politics/ct-trump-health-care-executive-order-20171012-story.html
(B) Trump’s health care order: What’s in it?, By Brittany De Lea, http://www.foxbusiness.com/politics/2017/10/12/trumps-health-care-order-whats-in-it.html
(C) Foiled in Congress, Trump Moves on His Own to Undermine Obamacare, By ROBERT PEAR and REED ABELSON, https://www.nytimes.com/2017/10/11/us/politics/trump-obamacare-executive-order.html?_r=0
(D) Trump begins Obamacare dismantling with executive order, by Tami Luhby and Kevin Liptak, http://www.cnn.com/2017/10/12/politics/trump-obamacare-executive-order/index.html
(E) How Narrow Networks Doom Trump’s Plan For Insurance Sales Across State Lines, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/08/how-narrow-networks-doom-trumps-insurance-sales-across-state-lines/#5b1ce52335f9
(F) Mulvaney on Trump’s Message to GOP: ‘Keep Your Promises’, by KAILANI KOENIG, https://www.nbcnews.com/politics/congress/mulvaney-pres-trump-s-message-gop-keep-your-promises-n808821
(G) Sen. Ron Johnson suggests compromise on health care, By Eli Watkins, http://www.cnn.com/2017/10/08/politics/ron-johnson-healthcare-cnntv/index.html
(H) ObamaCare enrollment groups likely to decrease services after Trump funding cuts, BY JESSIE HELLMANN, http://thehill.com/policy/healthcare/354879-obamacare-enrollment-groups-likely-to-decrease-services-after-trump-funding
(I) NJ LOSES FEDERAL FUNDING TO EXPAND ACA ENROLLMENT, by LILO H. STAINTON, http://www.njspotlight.com/stories/17/10/11/nj-loses-federal-funding-to-expand-aca-enrollment/
(J) Why Do Republicans (and Some Democrats) Vilify Single Payer?, by John Nichols, https://www.thenation.com/article/why-do-republicans-and-some-democrats-vilify-single-payer/

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CDC deactivated its emergency response center for Zika.. The first probable locally acquired Zika case in 2017 has been confirmed in Texas….

County health officials on Thursday reported the case involves a Laguna Heights resident who sought testing at a county clinic. The individual is believed to have contracted the virus through a mosquito bite.
“Based on the information that we have, the source of the transmission appears to be mosquito-borne that took place several months ago. Clinical test results show that this person may have had the virus 2-3 months ago and it is no longer active in her system,” said Dr. James W. Castillo, Cameron County Health Authority. “In addition, there is no evidence of any other mosquito transmitted cases related to this one.”
Health officials conducted an “epidemiological investigation of the index case household” and provided residents in the area with information on eliminating mosquito breeding areas.” (A)

“The first outbreaks of contagious disease are beginning on the island of Puerto Rico 10 days after Hurricane Maria strafed the U.S. territory with a direct hit, according to The Daily Beast, even as the federal response lags and President Donald Trump attacks Puerto Rico and its elected officials on Twitter….
Mayor Julia Navarro of Loiza, a city half an hour’s drive from San Juan, said residents are showing signs of Dengue fever, Zika virus and a runaway epidemic of conjunctivitis that has infected more than 300 people.
“I’m here because there are still murky waters clogged on my streets and residents have been showing symptoms of Zika, Dengue and conjunctivitis virus,” she said. “If I didn’t come here personally, I wouldn’t get any help.”…
The lack of running water means that opportunities for proper hygiene have largely disappeared, Ramos said, leaving the population vulnerable to cholera, hepatitis A, meningitis, and salmonella. “Without water supply, residents rely on stocking water to wash their mouth and do the dishes. This water is often stored incorrectly and this gets infected rapidly,” he explained.” (B)

Statistics from the Ministry of Health of Costa Rica confirm today 307 Zika cases in the first 38 weeks of 2017, while notifying 2,124 people likely to carry that dangerous arbovirus.
The weekly bulletin of the Directorate of Vector Control and the Costa Rican Institute for Research and Teaching in Nutrition and Health reports that among the confirmed cases are 60 pregnant women and four are likely to carry the disease. So far this year, four confirmed cases of a congenital syndrome associated with this condition were reported, as well as four other probable cases. (C)

“More than six dozen sentinel chickens, living in coops dotted around Los Angeles, make up one of the first lines of defense in this sprawling county’s fight against West Nile virus. The disease has been a background threat for years here, but cases have spiked this fall to worrisome levels. Six deaths have been reported by Los Angeles County this year — including three just last week.
And the cases are alarmingly severe: Of 98 reported infections here this year, 79 have led to serious neurological side effects, and 87 have required hospitalization. Because it’s still peak mosquito season, more deaths are expected….
West Nile virus causes no symptoms in 8 of 10 infected people, according to the Centers for Disease Control and Prevention. But some, particularly the very young and very old, can get fevers, fatigue, and flu-like symptoms. (Dr. Lyle Petersen, the director of the CDC’s division of vector-borne diseases, experienced that misery himself back in 2003, when he was infected with West Nile virus after going out to pick up his mail without insect repellent.)
The virus has caused more than 2,000 deaths in the U.S. since it first appeared in New York in 1999. States hit hardest in recent years include California, Arizona, Texas, Colorado, Oklahoma, Nebraska, and South Dakota. This year, 22 states have already reported 49 deaths and 658 of the most severe cases, known as “neuroinvasive,” which can involve meningitis, encephalitis, and paralysis.” (D)

“A mutated version of the decades-old Zika virus has been causing severe birth defects in countries like Brazil since 2015, and scientists are still trying to understand how it became so dangerous so fast.
As of early September, there had been 523 travel-related cases of the virus reported in Canada and four sexually transmitted cases, including 37 pregnant women.
In its most recent public health notice, issued on Sept. 13, Health Canada advised all travellers heading to countries where Zika has been identified to continue to take precautions — especially if they are pregnant or planning to get pregnant.
These hot spots include, but are not limited to, popular winter getaway destinations like Cuba, the Dominican Republic, Mexico, St. Lucia, Brazil, Costa Rica, and several other South/Central American and Caribbean nations.” (E)

“Scientists have started to unravel a key mystery about the Zika virus. And the findings are almost unbelievable.
“When I first started reading the study, I said, ‘Oh, my gosh, that’s amazing,’ says molecular biologist Alysson Muotri, at the University of California, San Diego, who wasn’t involved in the study.
The study — published Thursday in the journal Science — demonstrates how an obscure virus may have transformed into a global threat almost overnight.
For decades, Zika had been a relatively innocuous disease. Since its discovery in 1947, the mosquito-borne virus had been circulating around Africa and Asia, almost undetected. It caused only a mild illness — a fever, a rash and joint pain. About 80 percent of people had no symptoms at all. And outbreaks tended to be small.” (F)

“The U.S. Food and Drug Administration today approved the cobas Zika test, a qualitative nucleic acid test for the detection of Zika virus RNA in individual plasma specimens obtained from volunteer donors of whole blood and blood components, and from living organ donors. It is intended for use by blood collection establishments to detect Zika virus in blood donations, not for the individual diagnosis of Zika virus infection.” (G)

“Massachusetts Institute of Technology researchers have developed a paper-based test that is able to diagnose the presence of Zika virus in 20 minutes.
The MIT-developed test is a cheap, portable and easy-to-use diagnostic test that could be used in countries where Zika is prominent, but tests that measure viral RNA in the bloodstream are not.
“It’s important to have a single test that can differentiate between the four serotypes of Dengue and Zika, because they co-circulate. They’re spread by the same mosquito,” Kimberly Hamad-Schifferli, associate professor of engineering at the University of Massachusetts at Boston and co-senior author of the paper, said in a press release….
Zika virus is spread through the bite of an infected mosquito. According to the CDC, there have been 288 reported cases of Zika in the U.S. this year as of Oct. 4.” (H)

“In September 2017, the development of the US Army’s Zika vaccine—once a leading candidate in the Zika vaccine race—came to a halt after almost all federal funding for Zika R&D was cut short. This happened less than a year from the end of the global public health emergency. Funding will now resume only if the Zika epidemic re-emerges.
That R&D on diseases like Zika is not attractive to pharmaceutical companies is a well-known phenomenon. It usually takes a major public health crisis to shake up the playing field. With Ebola, for instance, funding for R&D increased 258% in 2015. The Zika outbreak had the same effect, and so will future outbreaks of similar diseases.
But funding spikes triggered by outbreaks are short-lived. They fuel an accelerated R&D race, with multiple pharmaceutical companies and research institutions jumping in. As soon as the fear factor begins to decline, so does the support for R&D. The looming possibility of another outbreak guarantees that some drug development will still occur, but only at a residual level.” (I)

“The U.S. Centers for Disease Control and Prevention deactivated its emergency response center for the Zika virus, as it seems the worst of the outbreak has passed…
On Jan. 22, 2017, the EOC was activated in response to Zika, which can have devastating effects during pregnancy. The CDC began its transition back to normal program operations Sept. 29.
In 2009, the EOC was activated for the H1Ni influenza pandemic. It was also activated for the 2014 Ebola outbreak.
Although the center is closing, the CDC will continue to work to protect people affected by Zika and coordinate with federal, state and local governments to help families touched by the virus. In its announcement, the agency emphasized that Zika is still a risk in the U.S.A.” (J)

(A) Zika case first in 2017, by LAURA B. MARTINEZ, http://www.valleymorningstar.com/news/local_news/article_74135444-aa47-11e7-b2eb-b799afd87eb8.html
(B) Disease outbreaks begin in Puerto Rico even as Trump attacks its citizens on Twitter, by David Ferguson, https://www.rawstory.com/2017/09/disease-outbreaks-begin-in-puerto-rico-even-as-trump-attacks-its-citizens-on-twitter/
(C) Costa Rica Confirms 307 Zika Cases, http://www.plenglish.com/index.php?o=rn&id=19007&SEO=costa-rica-confirms-307-zika-cases
(D) Deadly West Nile virus cases are spiking in LA. The first line of defense: chickens, by USHA LEE MCFARLING, http://www.pbs.org/newshour/rundown/deadly-west-nile-virus-cases-spiking-la-first-line-defense-chickens/
(E) Planning a winter getaway? Zika warnings remain in place as travel season looms, byy Monique Scotti, https://globalnews.ca/news/3789212/zika-virus-warnings-canada-travel-season-looms/
(F) How Zika Became So Dangerous For Babies, by Michaeleen Doucleff, http://www.npr.org/sections/goatsandsoda/2017/09/28/554054047/how-zika-became-so-dangerous-for-babies
(G) FDA approves first test for screening Zika virus in blood donations, https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm579313.htm
(H) This paper-based test quickly diagnoses Zika, by Danielle Kirsh, http://www.medicaldesignandoutsourcing.com/paper-based-test-quickly-diagnoses-zika/
(I) No Vaccines Before the Next Zika Outbreak?: A Case for IP Preparedness, by Dennis Crouch, https://patentlyo.com/patent/2017/10/vaccines-outbreak-preparedness.html
(J) CDC shutters Atlanta-based Zika emergency operations center, by Ellie Hensley, https://www.bizjournals.com/atlanta/news/2017/10/04/cdc-shutters-atlanta-based-zika-emergency.html

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Trump: “I want to focus on North Korea not ‘fixing somebody’s back’,…Let the states do that.” As “synthetic repeal” of ObamaCare is underway.

“President Trump praised health care block grants on Saturday, saying they allow the states to focus on health care, but said he would rather focus his energy on tensions with North Korea than “fixing somebody’s back or their knee.”
“You know in theory, I want to focus on North Korea, I want to focus on Iran, I want to focus on other things. I don’t want to focus on fixing somebody’s back or their knee or something. Let the states do that,” ….
“The block grant concept is a very good concept, and if you have good management, good governors, good politicians in the state, it’ll be phenomenal,” he continued. (A)

“The Trump administration issued rules Friday that immediately carve broad exceptions to the Affordable Care Act’s promise of no-cost contraceptive coverage, touching off fresh lawsuits and renewed debate about the proper scope of religious liberty.
The rules significantly widen the range of employers and insurers that can invoke religious or moral beliefs to avoid the ACA requirement that birth control pills and other contraceptives be covered by insurance as part of preventive care. Administration officials and their allies on the right downplayed the impact of the change on American women, while women’s rights and civil liberties groups portrayed it as a massive, discriminatory act.” (B)

“Stymied in his efforts to repeal the Affordable Care Act, President Trump is poised to issue an order that could ease some federal rules governing health insurance and make it easier for people to band together and buy coverage on their own, administration officials said Saturday.
One official said the directive could move the president a step closer to one of his longstanding goals: allowing consumers to buy health insurance across state lines. Conservatives say that interstate sales could expand options for consumers, increase competition in the insurance market and perhaps lower costs.
The order, which the administration officials said was likely to be announced in the coming week, would instruct three cabinet departments to take actions to help individuals and small businesses join together to buy insurance through arrangements known as association health plans. Such plans could be sponsored by trade and professional groups and community organizations.” (C)

“Legislation to rescue the Children’s Health Insurance Program sailed through a Senate committee on Wednesday, but touched off a partisan conflict in the House, diminishing hopes that the popular program would be quickly refinanced.
Funding for the program expired on Sunday, and state officials said they would soon start notifying families that children could lose coverage if Congress did not provide additional money. It was impossible to say when Congress might pass a bill and send it to President Trump…
But in the House Energy and Commerce Committee, lawmakers brawled Wednesday over a similar bill to provide money for the children’s health program. Democrats strongly support the program, but complained that Republicans would take money from Medicare and the Affordable Care Act to offset the cost.” (D)

“President Donald Trump said on Saturday that he had talked with Senate Minority Leader Chuck Schumer to see if Democrats want to help on a “great HealthCare Bill” — but Schumer separately indicated the conversation didn’t exactly go smoothly.
“”I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!” the president wrote on Twitter Saturday morning.
Schumer, in a statement, said Trump had suggested another Obamacare repeal-and-replace effort, which the New York Democrat said was a non-starter.
“The president wanted to make another run at repeal and replace and I told the president that’s off the table,” Schumer said. “If he wants to work together to improve the existing health care system, we Democrats are open to his suggestions. A good place to start might be the Alexander-Murray negotiations that would stabilize the system and lower costs.”” (E)

“”All of the things Trump and his administration have done on health care — not just pushing for repeal-replace, but independently cutting off enrollment outreach, keeping insurers in limbo about their payments, reportedly putting the kibosh even on Republican governors’ efforts to stabilize their markets, all of it — cuts in the exact opposite direction of anything Schumer would want or could abide.”” (F)

“Andy Slavitt, a former top health-care official in the Obama administration, warned on Twitter Thursday that the administration’s “sabotage” of the law added up to what he called “synthetic repeal,” meaning a range of small steps that add up to repealing ObamaCare even if Congress doesn’t act.” (G)

(A) Trump: I want to focus on North Korea not ‘fixing somebody’s back’, by JULIA MANCHESTER, http://thehill.com/homenews/administration/354419-trump-on-health-care-block-grants-i-would-rather-focus-on-iran-north
(B) The Trump administration just changed the rules on contraception coverage, by Amy Goldstein, Juliet Eilperin and William Wan, https://www.washingtonpost.com/national/health-science/trump-administration-could-narrow-affordable-care-acts-contraception-mandate/2017/10/05/16139400-a9f0-11e7-92d1-58c702d2d975_story.html?utm_term=.a5c305026020
(C) Trump Poised to Sign Order Opening New Paths to Health Insurance, by ROBERT PEAR, https://www.nytimes.com/2017/10/07/us/politics/trump-association-health-plans.html?_r=0
(D) Bill to Rescue Children’s Health Program Hits Snag in House, by ROBERT PEAR, https://www.nytimes.com/2017/10/04/us/politics/children-health-insurance-program-congress.html
(E) Trump reached out to Schumer to work on ‘great HealthCare Bill’, by BRENT D. GRIFFITHS and SEUNG MIN KIM, http://www.politico.com/story/2017/10/07/trump-says-that-he-has-reached-out-to-schumer-on-health-care-243560
(F) Trump phones a friend on health care, by Jonathan Swan and Mike Allen, https://www.axios.com/trump-confirms-his-phone-call-with-chuck-schumer-2494036970.html
(G) Critics see Trump sabotage on ObamaCare, by PETER SULLIVAN AND RACHEL ROUBEIN, http://thehill.com/policy/healthcare/354308-trump-sabotage-seen-on-obamacare

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