When I was a kid the only thing as scary as the polio epidemic was practicing getting under our desks for a nuclear attack…

It was 1952 and we lived in Haddonfield, New Jersey and the public swimming pool was closed for the duration. A town in full panic!

So today’s New York Times article on a polio outbreak in Syria is particularly disconcerting.
Polio Paralyzes 17 Children in Syria, W.H.O. Says (A)
“The polio virus, once thought to verge on eradication, is one of the most contagious diseases in inadequately protected areas. One confirmed case of paralysis is considered an outbreak, as doctors assume it means up to 200 other people may have been exposed to the virus.”…..
“Unlike Syria’s first polio outbreak in 2013, caused by a wild strain that paralyzed 36 children before it was brought under control, the new outbreak derived from the polio vaccine itself…..
The vaccine, a weakened form of the polio virus that triggers the immune system’s response, is secreted in the waste of vaccinated children, and over time can mutate into an infectious strain that may afflict the unvaccinated. The risks are especially high in areas where not all children have received the vaccine and where the mutated virus can spread from contaminated sewage or water.”

A 2012 article noted:
“In 1952 alone, nearly 60,000 children were infected with the virus; thousands were paralyzed, and more than 3,000 died. Hospitals set up special units with iron lung machines to keep polio victims alive. Rich kids as well as poor were left paralyzed.
Then in 1955, the U.S. began widespread vaccinations. By 1979, the virus had been completely eliminated across the country.
Now polio is on the verge of being eliminated from the world. The virus remains endemic in only two parts of the globe: northern Nigeria and the border between Afghanistan and Pakistan.” (B)

In a world full of conflict such Syria, Iraq and Yemen (C) are we likely to see a broad reemergence of polio?


Are we prepared for emerging viruses?
“Whatever the explanation, hepatitis C (1989), West Nile virus (1999), SARS (2003), Chikungunya (2005), swine flu (2009), MERS (2012), Ebola (2014) and Zika (2015) have all since had their time in the media spotlight. A further 33 diseases have featured in the World Health Organization’s Disease Outbreak News since its inception in 1996. Of the “big eight” listed above, six are known zoonotic diseases – and the remaining two (hepatitis C and Chikungunya) are assumed to be so, although the animal reservoir remains undiscovered.”

To learn more click on http://doctordidyouwashyourhands.com/2017/05/ebola-is-back-in-africa-is-zika-next-are-we-prepared/
ZIKA UPDATE #1. EBOLA is back in Africa. Is ZIKA next? Are we prepared?
Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).




(A) Polio Paralyzes 17 Children in Syria, W.H.O. Says by Rick Gladstone, https://www.nytimes.com/2017/06/20/world/middleeast/syria-polio-children-paralyzed.html
(B) Wiping Out Polio: How The U.S. Snuffed Out A Killer by Jason Beaubien, http://www.npr.org/sections/health-shots/2012/10/16/162670836/wiping-out-polio-how-the-u-s-snuffed-out-a-killer
(C) 10 Conflicts to Watch in 2017 by Jean-Marie Guéhenno, http://foreignpolicy.com/2017/01/05/10-conflicts-to-watch-in-2017/

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Should doctors and patients call each other by their first names? R-E-S-P-E-C-T (Aretha Franklin)

Recently I visited a medical specialist I have known for twenty five years. Back then I was a new hospital President and he was a junior attending. About ten years later I became his patient. And hadn’t seen him in two years.

When he saw me he said “hello Dr. Metsch” and I responded “hello Dr. Green” then we switched to first names. Even though I retired ten years ago and he is now a senior attending our initial greeting reflected mutual respect.

Mid-career I worked in the President’s Office at Mount Sinai for ten years for four physician CEOs. I always called them Doctor even as my younger colleagues would call them by their first names; they bristled at this informality.

About that time (1988) this was written: “The paper discusses the moral difficulties physicians encounter when determining the level of formality they will use when addressing their patients. It is argued that physicians ought not to use a patient’s first name unless the patient also uses the physician’s first name. In short, physicians and patients should always address each other with the same level of formality. It is argued that this is so even when patients invite physicians to address them informally.” (A)

“Developing a good rapport with a patient is essential, and what transpires during a first meeting can set the stage for the ongoing relationship. But unfortunately, there are no definitive guidelines on how physicians and other providers should be addressed, how patients prefer to be addressed, or how staff should introduce themselves.” (B)

There are certainly various points of view on this.
“If I call a patient by their first name, it would seem only fair and equal that I offer up my first name. I have always addressed my patients by their last names and titles, particularly in San Antonio, Texas, where military titles are extremely important. Familiarity also seems inappropriate in an environment where the patient does not see the same provider at each visit and has to start from scratch. Long gone are the days of a family physician who cared for three generations of the same family. Since a sizeable portion of patients and physicians may be offended by the use of their first name, it seems best that, unless invited to do so, we stick to formal titles.” (C)

“I address my patients (over the age of 18) by their titles and last names unless they have given me permission to do otherwise. When I meet new patients, I address them by their first and last names and then ask them how they would like for me to address them. My expectation is that they will address me as I prefer to be professionally addressed: “Dr. Middleton.”” (D)

Maybe I’m old school but I think all successful patient-doctor relationships are based on mutual respect. If a physician calls a patient by his first name, she should allow the patient to do the same. If a physician wants to be called Doctor, then he should use Mr., Mrs., Ms. or Doctor, Professor, Reverend, Captain or any other appropriate title.

I think formality should prevail initially and over time informality might be mutually OK and here’s a good example:
“I have at least a hundred patients who call me James, Jimmy, Dr. James, Dr. Bowtie, Dr. S, Herr Doctor or Jim. I have no need of an ego-massaging label. The difference is that we have long-standing relationships, and those patients have usually asked permission. We are friends, colleagues, in battle against the dread disease. I gain satisfaction to have built relationships where mutual respect is expressed in this way. Even so, when the proverbial excrement hits the spinning blades, many of those patients revert to “doctor.” That makes emotional sense to me.” (E)

To this day I never call a doctor by his or her first name without asking first and being comfortable the answer will be “yes.”

“I speak to everyone in the same way, whether he is the garbage man or the president of the university.” Albert Einstein

(A) What doctors should call their patients, by Michael Lavin, http://jme.bmj.com/content/medethics/14/3/129.full.pdf
(B) Should Patients Call You by Your First Name?, by Roxanne Nelson, http://www.medscape.com/viewarticle/852371
(C) What’s In a Name: What Should Patients and Doctors Call Each Other?, by Richard C. Senelick, http://www.huffingtonpost.com/richard-c-senelick-md/patient-doctor-relationship_b_1357605.html
(D) Should doctors be addressed by their first name?, by Jennifer Middleton, http://www.kevinmd.com/blog/2011/05/doctors-addressed.html
(E) Calling a Doctor by His or Her First Name, by James C. Salwitz, http://www.medpagetoday.com/Blogs/KevinMD/56354


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REVISE and RECALIBRATE Obamacare. Prevent Republican’s “mean” plan.

It is obvious that Repeal and Replace shouldn’t and won’t happen.

After bussing republican House members to the White House Rose Garden several weeks ago to celebrate House passage of the American Health Care Act, President Trump now “… bluntly derided a House attempt to repeal the Affordable Care Act as “mean,” “ and said “that he expected the Senate to come up with something more generous…” (A)

President Trump tweeted “”2 million more people just dropped out of ObamaCare,” “It is in a death spiral. Obstructionist Democrats gave up, have no answer = resist!” (B)

We know that the Obama administration planned to look at the following changes: Expand The Medicaid Expansion; Simplify Health Insurance Plans; Fix Surprise Medical Bills; Extend Coverage For Kids; Buff Up The Cadillac Tax; Improve Insurance Provider Networks; Rein In Prescription Drug Costs (C)
Any big new program like Obamacare has a “million” moving parts and some assumptions in the initial algorithms need to be recalibrated. Fortunately there has been plenty of evaluation and recommendations to do a mid-course correction to maintain access and address affordability.

Here is a list of approaches that must be considered:

Some initial corrections: (D)
1. Patch things up: Since affordability is a big issue, the federal government could spend more money to bring down the costs that individuals and families face. This could be done directly by raising the level of subsidies available for plans purchased on the exchanges, or raising the income thresholds at which the subsidies phase out—or both. Alternatively, the government could offer more generous subsidies to insurance companies, particularly those serving high-risk populations, in which case they wouldn’t have to raise prices as much, or impose such large deductibles.
2. Apply some force: One of the big problems that insurers are facing is that too few healthy people, and too many sick people, are signing up for the plans sold through the exchanges. For insurers, that changes everything. Faced with higher claims per enrollee than they expected, they seek to raise their prices, which makes healthy people, especially young healthy people, even less likely to sign up the following year. If unchecked, this process could lead to a spiral of rising prices and falling enrollment.
3. An obvious way to address this problem would be to drastically raise the fines that people face if they don’t purchase insurance. Under the terms of the Affordable Care Act, getting enrolled wasn’t meant to be a choice—it was a legal obligation. For political reasons, however, the penalty for flouting this “individual mandate” was set at a very low initial level, which is supposed to grow gradually. In 2015, the fines started at three hundred and twenty-five dollars per adult
4. Generally speaking, private insurance markets only work well when there is a large and diversified risk pool. If we are going to rely on them to provide universal, or near-universal coverage, the individual mandate will have to be enforced. That means raising the penalties for non-compliance and enforcing them effectively.
5. The Public Option: The rising cost of health care is an issue all over the world. The way most countries have dealt with it is by enrolling the entire population, or almost all of it, in a single-payer system, and using the bargaining leverage that creates (usually coupled with administrative fiat) to keep down costs. So far, the American political system, which is highly vulnerable to capture by powerful interest groups, such as doctors, hospitals, and pharmaceutical companies, has resisted going down this route. But this may be changing.

Stabilize the marketplace: (E)
6. “Marketplaces will only succeed if enough insurers participate, and many are running away from what they perceive as a high-risk, low-reward market opportunity,” …..All of this — insurer withdrawals and sharply escalating premiums — was avoidable and is fixable. We know how to draw insurers into markets, keep them there, and limit premium growth. We can do so by subsidizing plans more and by limiting their risk of loss. We’ve done both before.”
7. The Medicare Modernization Act also established Medicare’s prescription drug program, Part D, which offers another lesson. It’s also run entirely through private plans. They’re cushioned against large losses by a risk corridor program. This helps plans stay in the market if they miscalculated the mix of patients they’d attract, and it allows them to keep premiums lower than they might need to if they had to hedge against the full brunt of potential losses.
8. The Affordable Care Act included a risk corridor program for marketplace plans, too, but it expires at the end of this year. So does a reinsurance program that compensates insurers for unusually high-cost enrollees. Following the model of Part D and making the risk corridor program permanent, as well as the reinsurance program, could help stabilize the marketplaces.

Policy fixes that could plausibly improve Obamacare and attract bipartisan support. (F)
9. Defuse the Crisis. The leading enemy of stability is uncertainty, and for insurers who must decide what to do about the exchanges by June, the leading source of uncertainty before last Friday was the Republican repeal push itself. That threat has apparently subsided, but the House lawsuit over cost-sharing subsidies could still blow up the exchanges. The House put the suit on hold after Trump’s election, anticipating Obamacare’s repeal, but if the Republicans want to avoid a major mess, they need to make the suit go away and make sure the subsidies keep flowing.
10. Insure the Insurers: The Democratic push for health reform in 2010 relied on what The Washington Post described as “the near-daily demonization of the insurance industry.” Obama routinely attacked “insurance company bureaucrats who raise premiums and deny care.” Pelosi called them “villains.” And Obamacare included tough new rules that prohibited them from discriminating against customers with pre-existing conditions or capping how much they could spend on any customer.
11. Relax the Rules: The best evidence so far that the Trump administration hopes to prevent the kind of implosion the president keeps predicting is a new set of rules his Department of Health and Human Services recently proposed for the exchanges. The rules involve fairly modest adjustments for the 2018 enrollment, giving insurers more flexibility to offer slightly more generous plans while closing loopholes the insurers thought consumers were using to game the system. But they amount to an insurer wish list, which suggests a desire to keep insurers happy on the exchanges.
12. A Drug Deal: Obamacare has helped reduce the overall growth of health care costs to the lowest rate in half a century, but prescription drug prices have continued to soar. The cost of six brand-name diabetes medications rose more than 150 percent over the past six years. Multiple sclerosis drugs now cost more than $5,000 a month, increasing more than fivefold since 2001. Connolly says the nonprofit plans she represents now spend more on drugs than hospitalization. “That’s mind-boggling,” she says. “There’s no rhyme or reason to it, and it’s driving up premiums.”

Changes that would help bring down premiums on the exchanges. (G)
13. Require all insurers who want to sell in the individual insurance market to offer their plans through the exchange, so they couldn’t cherry-pick individuals outside the exchange (this is an idea championed by Henry Aaron of the Brookings Institution).
14. Reduce the waiting period for those on disability insurance to get Medicare coverage from two years to six months to move some of the very high-cost enrollees out of the individual-market pool.
15. Require any insurer that wants to offer a Medicare Advantage plan in an area also to offer a plan in the marketplace for under-65 enrollees.
16. Have the federal exchange adopt the procedures used by California in actively bargaining with plans instead of acting as a passive clearinghouses.
17. Create a public option for those aged 55-64 clearly identified as an early buy-in to Medicare.Create a second federally run public option for enrollees from 18 to 54.
18. Restore the risk corridor and reinsurance provisions that have expired that were intended to protect exchange plans against adverse selection.

A good summary – (H)
“First, despite some genuine problems, the Affordable Care Act is mostly working quite well.
Second, far from solving the problems of Obamacare, the Republicans’ AHCA would have made them worse.
Third, real leaders don’t run away from problems; they fix them. Fourth and most important, a compromise plan could have appealed to — and could still appeal to — enough members of both parties to pass.”



(A) Trump, in Zigzag, Calls House Republicans’ Health Bill ‘Mean’, by Thomas Kaplan, et al, https://www.nytimes.com/2017/06/13/us/politics/trump-in-zigzag-calls-house-republicans-health-bill-mean.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
(B) Trump: Dems ‘gave up’ on fixing ObamaCare, by Rebecca Savransky, https://www.nytimes.com/2016/11/15/upshot/politics-aside-we-know-how-to-fix-obamacare.html?_r=0
(C) How Obama Would Fix Obamacare If Congress Would Let Him, by Jeffrey Young http://www.huffingtonpost.com/entry/how-obama-would-fix-obamacare_us_56bcd8d6e4b0c3c550506e19
(D) Three Ways to Fix Obamacare, by John Cassidy, http://www.newyorker.com/news/john-cassidy/three-ways-to-fix-obamacare
(E) Politics Aside, We Know How to Fix Obamacare, Austin Frakt, https://www.nytimes.com/2016/11/15/upshot/politics-aside-we-know-how-to-fix-obamacare.html?_r=0
(F) Four Things Trump Could Do Right Now To Fix Obamacare, by Michael Grunwald, http://www.politico.com/magazine/story/2017/03/four-things-trump-could-do-right-now-to-fix-obamacare-214962
(G) Obamacare has some problems. Here’s how we can fix them, by Paul Waldman, https://www.washingtonpost.com/blogs/plum-line/wp/2016/10/25/obamacare-has-some-problems-heres-how-we-can-fix-them/?utm_term=.4f04717a4c90
(H) Want to fix Obamacare? Here’s how by Henry Aaron, http://www.nydailynews.com/opinion/fix-obamacare-article-1.3013226



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Study Findings: Five percent of pregnant women with a confirmed Zika infection.. went on to have a baby with a related birth defect

DOCTOR tracked ZIKA last year and proposed the designation of REGIONAL EMERGING VIRUSES REFERRAL CENTERS.
It seems that when it was an isolated mainland event in south Florida, public concern disappeared and public health authorities breathed a sigh of relief.
Even though we now know that more ZIKA outbreaks are likely and that the consequences for some babies will be catastrophic, authorities apparently are leaving every hospital to plan on its own.
Here’s one reason centralized planning is a necessity and Referral Centers need to be designated.

The New York Times story, by Catherine Saint Louis, noted:(A)
“Women who do not have any symptoms of Zika virus still may give birth to a baby with Zika-related birth defects, research has shown. The only way to catch those infections is to screen women because they may have been exposed to Zika-infected mosquitoes or may have had sexual contact with an infected partner.
In this new report, “The presence or absence of symptoms was not predictive of whether a baby would be damaged,” … “There were women who had asymptomatic Zika whose babies were damaged.”
Currently, only about 60 percent of babies born alive in United States territories had results of Zika laboratory testing reported to pregnancy and infant registries. It’s important that all babies who may have been affected are monitored, as early intervention can help.
For instance, some babies who appear normal at birth later develop an unusually shrunken head. Only with long-term tracking can health officials get an accurate estimate of the scope of the problem.”

Previous ZIKA related DOCTOR posts:
ZIKA UPDATE #1. EBOLA is back in Africa. Is ZIKA next? Are we prepared? (B)
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care! (C)

Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” (D)

(A) https://www.nytimes.com/2017/06/08/health/zika-birth-defects-cdc.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(B) http://doctordidyouwashyourhands.com/2017/05/ebola-is-back-in-africa-is-zika-next-are-we-prepared/
(C) http://doctordidyouwashyourhands.com/2016/09/all-pregnant-women-with-zika-diagnosed-at-community-hospitals-must-be-referred-to-academic-medical-centers-for-prenatal-care/
(D) http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/

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Over-testing can lead to over-diagnosing which can lead to over-treating. (A)

With the guidance of an experienced and thoughtful physician I just made a decision to end a course of diagnostic testing after slowly getting to that decision point.

But I have family members and friends who have gone through a full “best practices” diagnostic regimen only to wind up in an ambiguous situation, then having treatment that may or may not have been necessary, too often without getting a second opinion.

So, as usual, I started Googling:
Dr. Atul Gawande a prominent Harvard Medical School Professor of Surgery and New Yorker writer reflected on eight patients he saw in his practice one day, after reviewing their medical histories.
“To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (B)

Dr. H. Gilbert Welch, a professor at Dartmouth Medical School, and a nationally recognized expert on the effects of medical testing, wrote “….. the conventional wisdom is that more diagnosis—particularly, more early diagnosis—means better medical care. The logic goes something like this: more diagnosis means more treatment, and more treatment means better health. This may be true for some. But there is another side to the story. More diagnosis may make healthy people feel more vulnerable—and, ironically, less healthy. In other words, excessive diagnosis can literally make you feel sick. And more diagnosis leads to excessive treatment—treatment for problems that either aren’t that bothersome or aren’t bothersome at all. Excessive treatment, of course, can really hurt you. Excessive diagnosis may lead to treatment that is worse than the disease.” (C)

In another article Dr. Welch wrote this case study (very abbreviated here, link to full text is in the footnotes)
“Mr. Nadeau was eighty-five and in excellent health. He went to see his doctor simply for a routine checkup. The doctor performed a careful physical exam. Everything looked good, except for a bulge he thought he felt in Mr. Nadeau’s belly—a bulge that might be an abdominal aortic aneurysm. ….
The ultrasound showed that Mr. Nadeau’s aorta was normal…But the ultrasound found something else to worry about. It found something abnormal on Mr. Nadeau’s pancreas….A CT scan showed the pancreas was normal.
But the CT scan found something else to worry about. It found a nodule on Mr. Nadeau’s liver. The radiologist recommended a liver biopsy to see what the nodule was (it could be cancer too). ….The pathologic diagnosis was hemangioma, a benign growth made up of lots of blood vessels.
Given that a small knitting needle was cutting through a growth full of blood vessels, you won’t be surprised by what happened next. Bleeding. Mr. Nadeau was in the hospital for a week……
That’s too much medicine. (D)

Here are some ways you can play a role in assuring appropriate levels of diagnostic testing:
1. Do some homework using CHOOSING WISELY. Choosing Wisely is an initiative of the ABIM Foundation in partnership with Consumer Reports that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. http://www.choosingwisely.org/
2. Five Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure. Do I really need this test or procedure? What are the risks and side effects? Are there simpler, safer options? What happens if I don’t do anything? How much does it cost, and will my insurance pay for it? (E)
3. Second opinions are fairly routine. They bring peace of mind and encourage patient engagement… “If your physician doesn’t support you getting a second opinion, see how fast you can run.”… “Any doctor who is any good at what they do will welcome a second opinion, because it will usually be a confirming opinion.” (F)
4. As you get referred to specialists make sure your PRIMARY CARE PHYSICIAN keeps fully informed, coordinates your care and helps you fully understand your options.

(A) Over-Testing, Over-Diagnosis & Emergency Medicine: Does it Exist and Does it Matter?, by Rick Bukata, https://medium.com/@emabstracts/over-testing-over-diagnosis-emergency-medicine-does-it-exist-and-does-it-matter-fabc10d9e252
(B) Overkill, An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? by Atul Gawande, The New Yorker, http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
(C) ‘Overdiagnosed’ by Gilbert Welch et al, NYT, http://www.nytimes.com/2011/01/25/health/25zuger_excerpt.html
(D) There Is Such a Thing As Too Much Medical Care, by H. Gilbert E. Welch, http://www.sciencefriday.com/person/h-gilbert-welch/
(E) http://consumerhealthchoices.org/wp-content/uploads/2015/08/5QuestionsCard-ER.pdf
(F) A Patient’s Guide to Second Opinions, by Kristine Crane, http://health.usnews.com/health-news/patient-advice/articles/2014/07/23/a-patients-guide-to-second-opinions

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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Stigmatizing Medicaid Recipients with false facts

Speaking at the release of President Trump’s first budget, Mick Mulvaney, the White House budget director, said: “We’re going to measure compassion and success by the number of people we help get off of those programs and get back in charge of their own lives.  We’re not going to measure our success by how much money we spend, but by how many people we actually help.”  (A)

Mulvaney’s underlying premise: “We need people to go to work.  If you’re on food stamps, and you’re able-bodied, we need you to go to work.  If you’re on disability insurance and you’re not supposed to be — if you’re not truly disabled, we need you to go back to work.  We need everybody pulling in the same direction.” (B)

One of the big targets for reductions is Medicaid.

“We hear a lot about Medicaid in both the local and national media. It is oftentimes classified as a free program for those disinterested in working and paying their fair share, making it one of the most misunderstood and misperceived programs on the books.
It is imperative that everyone across the nation understand the purpose of Medicaid — that it is not for people who do not want to work or are simply looking for a handout. Medicaid is a safety net for everyone because we are all one medical crisis or catastrophic event away from financial ruin. It is a stepping stone for people when the unexpected occurs. It is for the middle class, for the financially stable, and even for those who once considered themselves upper class. If you have worked during your life, Medicaid is a program you helped fund and one that is available to you and your children when you need it the most. But few know exactly what that means.
To be clear, Medicaid covers more than just low-income families, it covers children, pregnant women, the elderly and the significantly disabled. AND, IT WILL COVER YOU IF EVER NECESSARY. (C)

In 2015, Medicaid provided health coverage for 97 million low-income Americans over the course of the year. In any given month, Medicaid served 33 million children, 27 million adults (MOSTLY IN LOW-INCOME WORKING FAMILIES), 6 million seniors, and 10 million persons with disabilities, according to Congressional Budget Office (CBO) estimates.
Children account for more than two-fifths of Medicaid enrollees but less than one-fifth of Medicaid spending. Only slightly more than one-fifth of Medicaid enrollees are seniors or persons with disabilities, but because they need more (and more costly) health care services, they account for nearly half of Medicaid spending. (D)

“When debating health care, we tend to talk far more about health insurance than about the institutions giving the actual care. Whatever the government decides to spend, poor people will get sick. And when they get sick enough, they will receive treatment. This is because federal law requires all hospitals to provide emergency care to all patients, regardless of their ability to pay.
For uninsured patients, lifesaving surgeries and treatments, along with a limited recovery period, are often covered through Emergency Medicaid funds. But patients who don’t fit neatly into our medical system for reasons of health or finances or their social situation — the “medical misfits” that any one of us can become under the wrong circumstances — need far more long-term support. This is often where safety-net hospitals step in.  (E)

If Medicaid is cut that does not mean that those formerly covered do not get care. They go to the nearest Emergency Room usually at an academic medical center or teaching hospital, “safety-net” hospitals, the same place we all go when the highest level of care is required. But the hospital either does not get paid or gets underpaid putting its finances in jeopardy, and therefore its surge capacity, the ability to take on community emergencies like the flu or Zika, and compromises its disaster preparedness.
“Almost 470,000 additional New Jersey residents wouldn’t have health insurance coverage under the House Republican-passed bill to repeal and replace the Affordable Care Act, according to a report released Thursday.
More than half of the 469,500 residents — 246,000 — would not be covered due to the American Health Care Act’s $834 billion cut to Medicaid, which would end the extra federal funding for new enrollees in states like New Jersey that expanded the program under the current health care law.” …of which about 56,000 would be in Hudson County served by Jersey City Medical Center where I was President and CEO for 17 years. (F)

Cutting Medicaid has a ripple effect on safety-net hospital sustainability which eventually will impact on access to health care for all of us.


(A)   Trump Budget Cuts Programs for Poor While Sparing Many Older People by Yamiche Alcindormay, NYT, https://www.nytimes.com/2017/05/22/us/politics/budget-food-stamps-poverty.html

(B)   Off-camera Briefing of the FY18 Budget by Office of Management and Budget Director Mick Mulvaney, https://www.whitehouse.gov/the-press-office/2017/05/22/camera-briefing-fy18-budge-omb-director-mulvaney

(C)   Medicaid: A Stepping Stone, Not a Stigma, by Mark A. Wallace, Hufffington Post, http://www.huffingtonpost.com/mark-a-wallace/medicaid_b_2396186.html

(D)   Policy Basics: Introduction to Medicaid, http://www.cbpp.org/research/health/policy-basics-introduction-to-medicaid

(E)    Where Will the Medical Misfits Go? Safety-net hospitals keep us all healthy by treating the patients no one else wants. Don’t let Republicans destroy them by Ricardo Nuilamay, NYT, https://www.nytimes.com/2017/05/26/opinion/sunday/safety-net-hospitals-health-care.html?_r=1

(F)    NJ Politics Digest: 470,000 in NJ Could Lose Health Coverage by Steve Cronin The Observer, http://observer.com/2017/05/nj-politics-digest-470000-in-nj-could-lose-health-coverage/

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…according to Iowa Republican Congressman Raúl R. Labrador. *

But New York Democratic Congressman Sean Patrick Maloney got it right when he said “Any member of congress who voted for the bill should be obligated to join a high risk pool.” ** 

HIGH RISK HEALTH INSURANCE POOLS in Trump/ Ryan Care carve out individuals with pre-existing conditions but does not guarantee them access to affordable health care.

This is under-the-radar but that’s why we need to be vigilant. So here’s a nerdy HIGH RISK 101.

The House Trump/ Ryan Care bill… would allow states to apply for waivers for certain ObamaCare provisions, such as a ban on insurers charging premiums based on a customer’s health and the requirement that insurers’ basic health plans cover certain services, like prescription drugs and mental health. 

How do we know this was a dodge?

An under-the-radar GOP amendment would have exempted members of Congress and their staffs to ensure that they will still be protected by those ObamaCare provisions. It was deleted after it was discovered. (A) When Congress tries to exempt itself, we know its shenanigans!

High-risk pools are private, self-funded health insurance plans organized by state to serve high-risk individuals who meet enrollment criteria and do not have access to group insurance. (B)

“High-risk pools are a key concept that helped House Republicans pass their replacement for the Affordable Care Act. That bill, the American Health Care Act…allows states to opt out of the requirement for insurers to cover people with preexisting conditions and set up high-risk pools for these people instead. A late amendment to the bill added $8 billion* in additional funding over five years for these potential pools, and that change garnered enough new Republican votes for AHCA to pass the House.” (C)

 “In a nutshell, high-risk pools: are prohibitively expensive to administer, are prohibitively expensive for consumers to purchase, and offer much less than optimal coverage, often with annual and lifetime limits, coverage gaps, and very high premiums and deductibles.” (D)

There have been state high-risk pools for 35 years, prior to the ACA. A recent Kaiser Health Foundation report on the state programs noted: “These high-risk pools likely covered just a fraction of the number of people with pre-existing conditions who lacked insurance, due in part to design features that limited enrollment. State pools typically excluded coverage of services associated with pre-existing conditions for a period of time and charged premiums substantially in excess of what a typical person would pay in the non-group market.” (E)

“…unless high risk pools are adequately subsidized, high premium costs will mean all high need consumers will not be able to afford coverage. State policymakers will need to address those implications as more consumers may face personal bankruptcies and unmet needs, and as states witness an increase in the number of uninsured and more demand for uncompensated care.” (F)

“The history of high-risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage — if they are able to obtain coverage at all.” (G)



 * https://www.washingtonpost.com/news/powerpost/wp/2017/05/06/nobody-dies-because-they-dont-have-access-to-health-care-gop-lawmaker-says-he-got-booed/?utm_term=.93a5e7087576

 ** WAMC public radio


(A)   House GOP health bill changes exempt members of Congress by Peter Sullivan, The Hill, http://thehill.com/policy/healthcare/330592-house-gop-health-bill-changes-exempt-members-of-congress

(B)    CONSUMER GUIDE TO HIGH-RISK HEALTH INSURANCE POOLS, NAHU,  http://www.nahu.org/consumer/hrpguide.cfm

(C)   Sounds Like A Good Idea? High-Risk Pools, by Julie Rovner and Francis Ying, KHN, http://khn.org/news/sounds-like-a-good-idea-high-risk-pools/

(D)   Why High Risk Pools (Still) Won’t Work, by  Jean P. Hall, Commonwealth Fund, http://www.commonwealthfund.org/publications/blog/2015/feb/why-high-risk-pools-still-will-not-work

(E)    High-Risk Pools For Uninsurable Individuals, by Karen Pollitz,   http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/

(F)    High Risk Pools Deja Vu – Lessons from States, Questions for Policymakers, by Trish Riley and Anita Cardwell, NASHP,  http://www.nashp.org/high-risk-pools-deja-vu-lessons-from-states-questions-for-policymakers/

(G)  High-risk pools won’t match Obamacare’s protections for pre-existing conditions by Tami Luhby, CNN, http://money.cnn.com/2017/05/03/news/economy/high-risk-pools-obamacare-pre-existing




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