The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza (A)

“The emergency room at Good Samaritan Hospital has been so packed with patients suffering from miserable flu symptoms the past few weeks, with incoming ambulances lined up outside and hospital rooms jammed, the staff has gone to its “Code Green” nearly every day.
“It’s all hands on deck,” said Dr. David Feldman, chairman of Good Samaritan’s Emergency Department.
Hospital CEO Joe DeSchryver has picked up a broom to sweep out emergency rooms for the stream of patients. Grace Ibe, a vice president, has wheeled patients in gurneys upstairs. And CFO Jody Dial has come in at midnight to troubleshoot and bring pizza…
At hospitals around the Bay Area and across the country, those on the front lines of what is shaping up to be the worst flu season in a decade are struggling to keep up — and wondering whether it will get worse.
Doctors and nurses are working overtime and double shifts. Some have become sick themselves, causing staff shortages when they are needed most. As one doctor put it, in emergency departments where misery is often hidden behind ubiquitous blue masks, “there’s a lot of coughing, sneezing, crying and fever.”” (B)

“Because the flu is so common, we tend to minimize its importance. Consider the contrast with how the United States responded to Ebola a few years ago. We had a handful of infections, almost none of them contracted here. One person died. Yet some states considered travel bans, and others started quarantining people.
Worldwide, just over 10,000 people died in the 2014-15 West African outbreak of Ebola: a relatively new, frighteningly contagious illness that people feared could become a global pandemic. It’s not surprising that it got a lot of attention. Yet the tens of thousands who died of influenza in the United States the same year barely made the news.”
The C.D.C. estimated that in the 2015-2016 flu season, the flu shot prevented more than five million cases of the flu, about 2.5 million medical visits and more than 70,000 hospitalizations. It was also estimated that it prevented 3,000 deaths.” (C)

“Influenza activity is widespread in all states except Hawaii (and the District of Columbia), according to the weekly flu report released Friday by the US Centers for Disease Control and Prevention.
“Flu is everywhere in the US right now,” said Dr. Dan Jernigan, director of the CDC’s influenza branch. “This is the first year we’ve had the entire continental US at the same level (of flu activity) at the same time.” It has been an early flu season that seems to be peaking now, he said, with a 5.8% increase in laboratory-confirmed cases this week over last.
There were 11,718 new laboratory-confirmed cases during the week ending January 6, bringing the season total to 60,161. These numbers do not include all people who have had the flu, as many do not see a doctor when sick.
Seven additional pediatric deaths were reported during the week ending January 6, bringing the total for the season to 20…
Different states, different responses
Alabama Gov. Kay Ivey declared a state public health emergency because of the flu on Thursday.
Scott Harris, acting state health officer at the Alabama Department of Public Health, said the influenza outbreak includes high activity throughout the state but particularly in metropolitan areas. This “crush” means some hospitals are operating over capacity, leaving some patients sitting in ERs. The public health emergency order helps health care professionals manage resources more efficiently and provides leeway so alternative care can be provided when personnel are unable to offer standard care…
Texas, which laboratory-confirmed 5,585 cases of the flu as of that date, is seeing activity levels “at the highest level — widespread — for a few weeks,” said Lara M. Anton, a press officer for the Department of State Health Services….
“There are reports of hospitals throughout the state that have needed to divert non-emergency ambulances for periods of time because of overcrowding in their ER,” Anton said. With most hospitals coming off “divert status” within the same day, the state’s hospital system has been managing the increased number of patients. The department continues to monitor the situation closely and “will step in with support when it is requested,” she said.
Texas is encouraging “anyone with symptoms to stay home and to see their health care provider, as antiviral medications may shorten the duration of their illness..” (D)

“Big-city hospitals in Texas have been overwhelmed this week by an influx of flu patients, and state health officials say influenza activity is widespread across the state.
At Parkland Memorial Hospital in Dallas, waiting rooms turned into exam areas as a medical tent was built in order to deal with the surge of patients. A Houston doctor said local hospital beds were at capacity, telling flu sufferers they might be better off staying at home. Austin’s emergency rooms have also seen an influx of flu patients.
But high emergency room volumes and filled hospital beds are “not uncommon” for this point during flu season, which runs from October to May, said Lara Anton of the Texas Department of State Health Services.
“We definitely know it’s widespread,” Anton said this week. “We have been at widespread for the past three weeks.” But she added that it’s too early in the season to know whether this year’s flu impact is extraordinary.
On Monday alone, Parkland’s emergency department had seen 930 patients — double what the hospital typically sees for people with flu symptoms by this time of year, Dr. Joseph Chang, associate chief medical officer for Parkland, told CBS11.” (E)

“A shortage of the plastic bags used to deliver fluids and medicine to sick and dehydrated patients is spurring area hospitals to find alternative delivery methods in the midst of a nasty flu season.
Hospitals in Michigan and nationwide have resorted to jury-rigging solutions and even reverting to labor-intensive methods rarely used since the advent of the IV bags that have become indispensable in modern medicine. Those alternatives have increased the workload for pharmacists and nurses, and are forcing some hospitals to beef up staffing to keep pace with the need.
The problem comes in the wake of Hurricane Maria, which devastated operations in Puerto Rico at the major manufacturing plants for the bags.
Hardest hit have been the small-volume IV bags of 100 milliliters or less that are used to infuse antibiotics, cancer medicines and other critical drugs. Prior to the shortage, the five-hospital Beaumont Health system reportedly went through about 50,000 per month. Beaumont gets its small IV bags from Baxter, the nation’s largest supplier of the mini-bags, whose manufacturing facilities in Puerto Rico were idled by the storm. Their operations are expected to be back to full production by the end of January, but experts say it will take time to replenish supplies…
The shortage has been exacerbated by the flu outbreak, which has spiked emergency room visits and hospital admissions across the country. Beaumont Health announced Friday it was imposing visitation restrictions at its hospitals due to high volumes of patients with upper respiratory infections, predominantly the flu.”..
“Some days we’re able to get saline solution, other days we can get dextrose,” he said. “We have to work very closely with our nursing staff and providers to make sure whatever changes we’re making are safe for the patients.”
Some of the alternatives implemented include using portable pumps instead to administer some medicines. Supportive medicines, like those for nausea or to calm anxiety, are given orally when possible. And nurses can hand-push medications into IV lines at the bedside as another alternative.
Communication among staff is critical to ensure patient safety, Smith emphasized. Karmanos uses its internal online communications system, tip-sheets and other methods to keep all staff informed of up-to-the-minute changes.
“Everybody has to be on the same page on what we’re doing,” Smith said. “The nurse at the bedside (needs to know) exactly what you’re doing.” (F)

“According to the numbers, this year’s flu season is in fact worse than usual. It got started early, and it’s been more severe. Twenty kids have died of the flu since October. And in the week ending January 6, 22.7 out of every 100,000 hospitalizations in the U.S. were for flu—twice the number of the previous week.
“Flu is everywhere in the U.S. right now,” Dan Jernigan, director of the Center for Disease Control and Prevention’s influenza branch, said during a Friday press briefing. “This is the first year we’ve had the entire continental U.S. be the same same color”—referring to a map of state-by-state estimate of flu activity. That color is brown, meaning the flu is “widespread” everywhere in the U.S. except for Hawaii and the District of Columbia.
Several factors have come together make this year’s flu worse for patients who get sick and for hospitals trying to treat them.
First, the virus. Fears of a bad flu season first began in the early fall, after public health officials noticed a worse-than-average flu season in the southern hemisphere. The dominant circulating strain this year is H3N2, which hits humans harder than other strains. Scientists don’t really know why, but flu seasons where H3N2 have dominated in the past have tended to be worse. STAT reporter Helen Branswell called it the “problem child of seasonal flu.”
H3N2 (red) makes up the majority of lab-confirmed cases of flu this season. (CDC)
Second, the vaccine. This year’s vaccine was only 10 percent effective against the problematic H3N2 strain in Australia…
In recent years, researchers have tried to stop relying on chicken eggs. This flu season, for the first time, the H3N2 component of one type of vaccine, Flucelvax, was made in dog cells rather than chicken eggs. However, Flucelvax is more expensive and less widely available; most people who got the vaccine this year likely got the ones grown in chicken eggs. Researchers also are pursuing a universal flu vaccine that works against all strains.” (G)

“If you experience flu-like symptoms, you should first call or visit your primary care provider, who can quickly assess your health needs. By taking this step, you can avoid potentially long wait times at your nearby emergency department.
Your physician can also determine whether you need additional care because of the severity of symptoms or other risk factors, such as age (under 2 or over 65), pregnancy, a compromised immune system, or a chronic disease such as diabetes, heart disease or neurological disorders.
Each year, millions of children get sick with the flu and thousands are hospitalized. Some kids are at higher risk of serious complications: those younger than five, and any child who has a chronic medical condition such as asthma, diabetes, or disorders of the brain or nervous system. However, even healthy children can develop complications.
The best way to protect children is a yearly, injectable flu vaccine. It is not too late to get a shot. The vaccine protects your child against flu illnesses, which can reduce visits to the doctor and missed school days, and can prevent hospitalizations.
Symptoms of the flu typically begin one to four days after exposure to the virus and, in children, last one to two weeks. In addition to the typical fever, cough, aches and fatigue, children are more likely than adults to suffer vomiting and diarrhea – which can lead to dehydration.
Call the pediatrician if your child develops a fever; starts breathing rapidly or has trouble breathing; is not drinking enough; is less responsive than normal; or has the flu, gets better, and then relapses with fever or cough.” (H)

“The C.D.C. recommends people who are hospitalized or at high risk for complications of the flu, such as older patients, pregnant women and those who are otherwise immunocompromised, take the antiviral drug oseltamivir, sold under the brand name Tamiflu, because observational data indicate it might reduce the likelihood of death.
Other researchers, including those at the Cochrane Collaboration, disagree, saying that there’s not enough evidence to support taking oseltamivir or its chemical cousin zanamivir (brand name Relenza). They question the wisdom of spending billions stockpiling them as many countries, including the United States, began doing during the swine flu scare in the mid 2000s. Indeed, the World Health Organization last year downgraded oseltamivir from its list of essential medicines. It may or may not help, depending on which study you look at.
For healthy people who get the flu, most researchers agree the data indicates oseltamivir taken within 48 hours of onset can reduce the duration by about two-thirds of a day. But at around $154 for a course of the medication, that may not be worth it, given that the side effects include nausea and vomiting.
“We wish we had better drugs that could wipe out flu,” said Angela Campbell, a medical officer with the C.D.C.’s Influenza Division. But she said oseltamivir is “what we have right now” and in outpatient situations “it’s really the clinician’s decision with the patient based on a number of factors,” including cost and effectiveness, whether it should be prescribed or not.
The C.D.C. also still recommends getting this season’s flu shot, despite its questionable prophylactic value, because it might reduce the severity of the flu should you contract it. In previous years, against strains other than H3N2, flu shots have had reported effectiveness of about 40 percent to 60 percent. (I)

“If ever there was a case where familiarity bred contempt, and that contempt represented grave danger, it is the flu. Our casual references to “cold and flu” epitomize that perilous mindset. We seemingly think of the flu, likely due to its predictably annual impositions and its long familiarity, as a nuisance on par with the common cold. In my years of patient care, this mentality has been confirmed by the frequent, popular conflation of the two conditions; patients who merely have colds routinely self-diagnose the flu…
There is a case to make, and one that has been made, that we are more vulnerable now than in 1918. The global population of humans is vastly greater; the global population of domestic animals is greater; the co-habitation of the two in much of Asia persists; and global travel means that an outbreak anywhere can be everywhere else far more expeditiously now than a century ago. That is all legitimate cause for serious concern.
There are, however, reasons to think we may be less prone to catastrophe than our early 20th century forebears. They experienced a flu pandemic during a grueling world war. While current posturing about nuclear arms and buttons on desks is far from comforting, we may hope to avoid a recurrence of that dire confluence.
There is much less abject global poverty now than in 1918. We have antiviral drugs that are at least often and partially effective against flu. The world’s population is better nourished. And, of course, we have monumental advances in medical care overall that allow for far more effective management of flu complications, such as pneumonia.
That’s all reassuring. But it is by no means a case for complacency. Nor does any resource we have defend against the pernicious corrosion of Internet conspiracy theories and anti-vaccination sentiment run amok. No, vaccines are not perfectly, unfailingly safe, and they are certainly not perfectively effective. But they need be neither to be monumentally safer than and preferable to the diseases they help prevent. That is true of influenza, as it is true of polio, and was true of smallpox. I favor natural approaches to health and medicine when they are known to work, but there is no alternative ever shown to do what vaccines do; arguments to the contrary simply abandon epidemiology for ideology…
That we were catastrophically unprepared to be “flu’d” in 1918 was a surprise for which we may blame the virus. If we are so “flu’d” again, however, then we will need to hold ourselves accountable, and suffer the shame of tragic complacency along with the inevitable cost in lives. We are forewarned; whether or not we choose to be forearmed is up to us.” (J)

“You’ve no doubt heard the saying “feed a cold; starve a fever.” However, the healing power of nourishment and energy through foods is vital when you’re battling an intestinal virus or common cold in order to boost your immunity and give your body the energy it needs to fight off whatever illness is ailing you, particularly if you’re dealing with flu symptoms for several days or weeks.
Here are eight foods that are gentle on your body yet will help you overcome the flu…
Chicken Soup. There’s obviously some truth to the “Chicken Soup for the Soul” phenomenon. Not only is a steaming hot bowl of chicken soup comforting at time when you’re not feeling you’re best—each bowl contains vitamins, nourishment, minerals, and hydration benefits that you can’t get from starving a cold.
According to research from Mount Sinai, in Miami, Florida, chicken soup has the ability to improve air flow and flush out mucus in the nasal passages thanks to the copious amount of hot, steamy liquid within. A 1998 research report entitled “Coping With Allergies and Asthma” also found that a bowl of chicken soup actually contains anti-inflammatory properties that boost the tiny hairs-like follicles (known as cilia) in your nasal passages, which filter and stop the transportation of viruses, fungus, and bacteria from entering the body and causing nasty infections.” (K)

Hospital Pandemic Influenza Planning Checklist (L)
Planning for pandemic influenza is critical for ensuring a sustainable healthcare response. The Centers for Disease Control and Prevention (CDC), with input from other Federal partners, have developed this checklist to help hospitals assess and improve their preparedness for responding to pandemic influenza. Because of differences among hospitals (e.g., characteristics of the patient population, size of the hospital/community, scope of services), each hospital will need to adapt this checklist to meet its unique needs and circumstances.1 This checklist should be used as one of several tools for evaluating current plans or in developing a comprehensive pandemic influenza plan.

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.

(A) CDC quietly postpones nuclear war prep briefing to focus on the flu epidemic instead, by Ilene MacDonald, https://www.fiercehealthcare.com/healthcare/cdc-quietly-postpones-nuclear-war-prep-briefing-to-focus-flu-epidemic-instead?mkt_tok=eyJpIjoiT0RjMk56UXpZMlUwT0RnMCIsInQiOiJOSG9PSVk1XC9IZ0JuR3N3eEFwbElmSXlWZkQ0aHprVVFTbTNkVjBIVmNKUGpKcXROZDV3cTdZXC90TDFqVCt2RFBUeUFodDhsS3QwMER2bktyWmNCUU5hdno5ZndKVjdBUXBoU1l2bUhXcitjN2M1S09mbE9aWmc2d3ZaOGRYOGVoIn0%3D&mrkid=654508
(B) Flu deaths rise, patients pack Bay Area emergency rooms: ‘All hands on deck,’ doctor, by Julia Prodis Sulek, https://www.mercurynews.com/2018/01/14/flu-deaths-rise-patients-pack-bay-area-emergency-rooms-all-hands-on-deck-doctor-says/
(C) Still Not Convinced You Need a Flu Shot? First, It’s Not All About You, by Aaron E. Carroll, https://www.nytimes.com/2018/01/15/upshot/flu-shot-deaths-herd-immunity.html?_r=0
(D) Flu stomps the nation, overwhelming ERs and leaving 20 children dead, by Susan Scutti, http://www.cnn.com/2018/01/12/health/flu-surveillance-cdc/index.html
(E) Flu patients leave Texas hospitals strapped, by SYDNEY GREENE, https://www.texastribune.org/2018/01/11/flu-levels-rise-texas-officials-advise-public-be-aware/
(F) Detroit area hospitals’ IV bags drying up in flu season, by Karen Bouffard, http://www.detroitnews.com/story/life/wellness/2018/01/12/detroit-area-hospitals-iv-bags/109411668/
(G) The Perfect Storm Behind This Year’s Nasty Flu Season, by SARAH ZHANG, https://www.theatlantic.com/health/archive/2018/01/the-perfect-storm-behind-this-years-nasty-flu-season/550469/
(H) 2018 Flu Treatment, Prevention and How to Care for Others with the flu, https://www.lifespan.org/centers-services/primary-care-services/2018-flu-treatment-prevention-and-how-care-others
(I) In the Flu Battle, Hydration and Elevation May Be Your Best Weapons, by KATE MURPHY, https://www.nytimes.com/2018/01/12/well/live/flu-h3n2-virus-care-remedy.html
(J) Flu Us Twice?, by David L. Katz, https://www.huffingtonpost.com/entry/flu-us-twice_us_5a58b6f5e4b0d3efcf695772
(K) 8 Foods to Eat When Fighting the Flu, by Emily Lockhart, http://www.activebeat.co/diet-nutrition/8-foods-to-eat-when-fighting-the-flu/
(L) https://www.cdc.gov/flu/pandemic-resources/pdf/hospitalchecklist.pdf

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Opioid Crisis. President Trumps “thoughts and prayers have helped.. “But additional funding and resources would be more helpful.”

President Donald Trump in October promised to “liberate” Americans from the “scourge of addiction,” officially declaring a 90-day public health emergency that would urgently mobilize the federal government to tackle the opioid epidemic.
That declaration runs out on Jan. 23, and beyond drawing more attention to the crisis, virtually nothing of consequence has been done…
A senior White House official disputed the assessment of inaction, saying the emergency declaration has allowed the president to use “his bully pulpit to draw further attention to this emergency that he inherited.” The official added that the declaration has enabled federal agencies to “really change their focus and prioritize the crisis,” and that getting an effective media campaign underway “takes time.”…
In West Virginia, which has the highest drug overdose death rate in the country, Public Health Commissioner Rahul Gupta hasn’t seen any significant change under Trump’s emergency order. “His thoughts and prayers have helped,” Gupta said. “But additional funding and resources would be more helpful.”..
State health officials and policy experts say billions of dollars in new funding are needed to make a dent in the crisis. The Public Health Emergency Fund, which HHS could tap under the Trump declaration, has a balance of just $57,000, and the administration hasn’t proposed replenishing it. Rather than asking for new money, the administration can move funds around in existing agency budgets — but that just means taking money away from other health programs….
The White House official said the administration is “actively in discussion with Congress” about funding for the crisis.” (A)

Congress approved bipartisan legislation in 2016 that authorized $1 billion over two years for opioid crisis response grants to states, which was signed into law by Obama. The first $500 million was doled out last year. The rest is being held up in a larger fight over a bill to fund the government, but it is eventually expected to be appropriated and distributed to states. And other money that Trump has touted comes from the CDC and the Substance Abuse and Mental Health Services Administration — agencies whose budgets were kept mostly flat under the 2017 spending bill and would have been cut in Trump’s budget proposal for 2018…
The administration has emphasized a law-and-order approach, cracking down on drug offenses and trying to cut the flow of illegal drugs into the country. Attorney General Jeff Sessions recently challenged states that have voted to legalize marijuana.
Trump’s health department has routinely touted its “five-point” strategy to combat the opioid crisis: prevention, treatment and recovery; expanding access to the overdose reversal drug naloxone; improving data about the scope of the crisis; and supporting research on pain and how it is managed.
Nevertheless, Eric Hargan, the acting HHS secretary, said in November that the president was leaving it to Congress to decide whether more money should be appropriated. Democrats argued hypocrisy. (B)

“A majority of the public considers addiction to prescription pain medication a major problem nationally (53%) but does not deem it a national emergency (28%) (Politico–HSPH, 2017). Substantially fewer people see it as an emergency (16%) or a major problem (38%) in their own community (PBS–Marist, 2017). In a list of national health problems, abuse of prescription painkillers ranks fifth in the proportion of the public that considers it an extremely serious disease or health condition facing the country (28%; KFF, April 2016). Concern about prescription-drug abuse as a public health problem has grown over time. Nearly 4 in 10 people (38%) currently believe it’s an extremely serious public health problem, double the proportion (19%) who believed so in 2013 (Pew, 2013 and 2017). More than 6 in 10 (63%) believe that the problem of addiction to prescription pain medications has increased in the past year, 26% think it has stayed about the same, and only 2% believe it has decreased (PBS–Marist, 2017)….
An important finding from our review is that at a time when public- and private-sector leaders are seeking a substantial increase in government funding for opioid-addiction treatment programs and legislation requiring insurers to offer coverage for these treatments, polls show a large share of the public uncertain about the long-term effectiveness of treatment. Over the next few years, this impression could affect family referrals to treatment programs, as well as public support for them and for a government requirement that insurance cover their cost. There is a clear need for the medical and scientific communities to educate the public about the issues surrounding the potential effectiveness of treatment.” (C)

“Pharmaceutical manufacturers such as Purdue Pharma, Endo International plc (ENDP – Get Report) , Teva Pharmaceutical Industries Ltd. (TEVA – Get Report) , Johnson & Johnson Inc. (JNJ – Get Report) and Allergan plc. (AGN – Get Report) as well as distributors Cardinal Health Inc. (CAH – Get Report) , McKesson Corp. (MCK – Get Report) and AmerisourceBergen Corp. (ABC – Get Report) have all been challenged by various parties to take action in the opioid epidemic…
Ohio is ground zero, where ten people die every day from opioids leaving behind families and friends and creating holes in cities and towns in the Buckeye state that don’t heal easily. And there is a cost beyond the human. Children moved from addicted parents to foster care cost $45 million a year. Indeed, half the kids in foster care come from parents addicted to opioids. Counseling and medication costs $216 million a year. Treating kids who are born drug dependent adds another $130 million. Ohio estimates that work lost because of the opioid crisis, fatal overdoses, and medical expenses costs $4 billion a year. From 2011 to 2015 3.8 billion doses of opioid meds were prescribed in Ohio. The state only has 11.6 million residents. In 2016, it lost 4,050 of those residents to overdoses of opioids, heroin and fentanyl, a dangerous synthetic opioid, according to Ohio’s own data…
While the pharmaceutical companies may not be beating a path to Columbus to talk to DeWine, that doesn’t mean they aren’t responding. A spokesman for Janssen said in an email “We believe the allegations in the lawsuit against our company are both legally and factually unfounded. Responsibly used opioid-based pain medicines give doctors and patients important choices to help manage the debilitating effects of chronic pain. Janssen has acted in the best interests of patients and physicians with regard to opioid pain medicines, which are FDA-approved and carry FDA-mandated warnings about possible risks on every product label.”…
McKesson, the San Francisco-based drug distributor, has spent its share of time in the harsh glare of the media spotlight. Investigative stalwart 60 Minutes and the Washington Post teamed up on a December report that showed the infighting between the Drug Enforcement Agency and the Justice Department over how best to go after McKesson regarding allegations that the company had been careless in its distribution and sale of opioids. While the DEA felt it had a criminal case against the company and more than enough evidence of wrongdoing for federal prosecutors, the case never saw the inside of a courtroom. Prosecutors maintained the case didn’t merit criminal charges and wasn’t strong enough. At one point the DOJ allegedly suggested the DEA become friendlier with the pharmaceutical industry.
Instead the DOJ huddled with a team of lawyers defending McKesson, negotiating a settlement that included a $150 million fine and a suspension of four of McKesson’s drug warehouses and increased staffing as well as McKesson hiring an independent monitor.” (D)

“A federal judge on Tuesday set a goal of doing something about the nation’s opioid epidemic this year, while noting the drug crisis is “100 percent man-made.”
Judge Dan Polster urged participants on all sides of lawsuits against drugmakers and distributors to work toward a common goal of reducing overdose deaths. He said the issue has come to courts because “other branches of government have punted” it.
The judge is overseeing more than 180 lawsuits against drug companies brought by local communities across the country, including those in California, Illinois, Kentucky, Ohio and West Virginia. Municipalities include San Joaquin County in California; Portsmouth, Ohio; and Huntington, West Virginia.
Polster said the goal must be reining in the amount of painkillers available.
“What we’ve got to do is dramatically reduce the number of pills that are out there, and make sure that the pills that are out there are being used properly,” Polster said during a hearing in his Cleveland courtroom. “Because we all know that a whole lot of them have gone walking, with devastating results.”
The judge said he believes everyone from drugmakers to doctors to individuals bear some responsibility for the crisis and haven’t done enough to stop it…
Polster likened the epidemic to the 1918 flu which killed hundreds of thousands of Americans, while pointing out a key difference.
“This is 100 percent man-made,” Polster said. “I’m pretty ashamed that this has occurred while I’ve been around.” (E)

“The epidemic of drug overdose deaths is a national disaster. It claimed more than 64,000 lives in 2016, many of them by opioid overdoses. That’s far more than the number of deaths from HIV/AIDS in the peak year of 1995…
About half of opioid overdose deaths occur among men and women ages 25 to 44; it’s reasonable to assume that many are parents. Imagine the impact on a child when a parent overdoses at home or in a grocery store. Statistics can’t tally the trauma felt by a seven-year-old who calls 911 to get help for an unconscious parent, or the responsibility undertaken by a twelve-year-old to feed and diaper a toddler sibling, or the impact of school absences and poor grades on a formerly successful high school student.
Parental overdoses have an immediate impact on children. There’s also a cumulative impact as these children become adults and are themselves at risk from the same influences that drove their parents to drugs, overdoses, and early deaths.
Who are these children and adolescents? Newborns whose mothers are addicted to opioids. These babies may undergo withdrawal themselves and need special treatment. Children of all ages at risk for accidental ingestion or inhalation of toxic substances. Children living with an addicted parent, dealing with constant uncertainty and fear. Children who have taken over the role of family caregiver for younger siblings or for their addicted parents. Children who are removed from their homes and placed in foster or kinship care. Some of these children have unmet mental health care needs. Very young children exposed to toxic levels of stress that impair brain development.
No one knows how many of these vulnerable children there are in the U.S. because no one is counting. As a point of comparison, an advisory group to the British government estimated that there are between 250,000 and 350,000 children of drug abusers in the U.K. — about one for every drug user. The title of its report, Hidden Harm, applies equally well to American children. They remain hidden in families with addiction until a crisis erupts and law enforcement or child welfare agencies get involved.” (F)

“Policymakers mistakenly focus on doctors treating their patients in pain. By intruding on the patient-doctor relationship they impede physician judgment and increase patient suffering. But another unintended consequence is that, by reducing the amount of prescription opioids that can be diverted to the illicit market, they have driven nonmedical users to heroin and fentanyl, which are cheaper and easier to obtain on the street than prescription opioids, and much more dangerous.
Data from the Centers for Disease Control and Prevention show that from 2006 to 2010 the opioid prescription rate tracked closely with the opioid overdose rate, at roughly 1 overdose for every 13,000 prescriptions. Then, after 2010, when the prescription rate dropped and it became more difficult to divert opioids for nonmedical use, the overdose rate began to climb as nonmedical users switched over to heroin and fentanyl. There is a dramatic negative correlation between prescription rate to overdose rate of -0.99 since 2010.
The overdose rate is not a product of doctors and patients abusing prescription opioids. It is a product of nonmedical users accessing the illicit market.
The problem will not get better—it will probably only get worse—as long as we continue to call this an “opioid crisis.” The title is too nonspecific. This is a crisis caused by drug prohibition—an unintended consequence of nonmedical drug users accessing the black market in drugs. Policymakers should stop harassing doctors and their patients and shift the focus to reforming overall drug policy. A good place to start would be to implement harm reduction measures, such as safe syringe programs, making Medication Assisted Treatments like methadone and suboxone more readily available, and making the opioid antidote naloxone available over-the-counter, so it can be easier for opioid users to obtain. Even better would be a sober reassessment of America’s longest war, the “War on Drugs.”
Renaming the problem a “heroin and fentanyl crisis” might be a way to trigger a refocus.” (G)

“Attorney General Jeff Sessions’ reversal of an Obama-era policy that let legalized marijuana proliferate in many states across the U.S. may affect states that have medical marijuana and recreational pot use laws. It’s too early, though, to tell just how significant the impact will be.
On Thursday, Sessions rescinded a decision made in 2013 that adopted a policy of non-interference with marijuana-friendly state laws, the New York Times reported…
“Federal law normally trumps state law, so a violation of a federal criminal statute could result in significant penalties including imprisonment, even if the act is lawful under state law,”…With Sessions’ decision, people selling or using marijuana for medical purposes could be prosecuted. “As a result, it would pose a chilling effect on the use of marijuana for needed medical purposes, even if prescribed by a doctor in accordance with state law,”.
While medical marijuana can’t be legally prescribed, possessed, or sold under federal law, its use to treat some medical conditions is legal under many state laws, according to the American Cancer Society. Currently, 29 states have medical marijuana laws. The Sessions decision could put the kibosh on many of those “compassionate use” laws, though.
“It could exclude one of the key ways that physicians can help their patients and reduce suffering. It might also result in greater use of less effective and more addictive medications such as opioids,” Gostin says.
Currently, the U.S. is experiencing an opioid epidemic. Since 1999, the number of overdose deaths involving opioids quadrupled, and prescription opioids are a driving factor in the increase, according to the U.S. Centers for Disease Control and Prevention…
Under the Sessions policy reversal, a cancer patient currently using a marijuana-based drug to ease pain or nausea may have that right taken away.” (H)

“The opioid epidemic is now a full-blown national crisis, yet the federal government continues to dawdle. President Donald Trump declared opioid addiction a public health emergency, and he talks a tough game. But he has not taken forceful action. If he will not lead, Congress must — and now, before the crisis grows even worse…
This is a solvable problem, and through philanthropy we can make some progress. But real success requires much bolder leadership — and a far greater sense of urgency — from both elected officials and industry leaders…
We must stop doctors from over-prescribing opioids, especially when non-addictive pain medications (such as ibuprofen or acetaminophen) would be just as effective. More aggressive action is needed.
The Food and Drug Administration should allow only doctors who complete specialized education in pain management to prescribe opioids for more than a few days, a move FDA Commissioner Scott Gottlieb is considering. ..
Insurers and pharmacy benefit managers must better oversee opioid prescriptions. CVS Caremark has moved to limit coverage for opioid prescriptions. Others should follow its lead. These companies exist to help people lead better, healthier lives, and they should not be complicit actors in an addiction and overdose epidemic…
We must hold pharmaceutical companies accountable for the supply of prescription opioids.,,
We must start treating those with addiction disorders when they come in contact with emergency rooms, hospitals and clinics. …
We must stop stigmatizing the medications that have been proven to help people recover…
The federal government should incentivize cities and states to offer treatment to inmates, as New York City and a handful of other localities do…
We must develop better data. Existing statistics on misuse and overdose are out of date and often inaccurate….
We must do more to block the importation of heroin — and of fentanyl, much of which originates in China….” (I)

“What can health care providers do to address these problems?..
Researchers called persistent prescription opioid use “one of the most common complications after elective surgery.”
This is not to say that patients should be left writhing in pain in their hospital beds: We need to start using a multi-disciplinary and multi-modal approach to pain management. Surgeons need to engage in early education with their patients about post-operative pain management and the risks of medications, as well as setting realistic expectations about what post-surgery pain will be like.
Additionally, health care providers need to identify those most vulnerable to opioid addiction, including those with mental health issues or pre-existing substance abuse, and establish more sensitive processes that ensure they experience as little pain as possible without relying on potentially dangerous opioids.
We also need to rely more heavily on other medications in our arsenal, such as acetaminophen, non-steroidal anti-inflammatories, muscles relaxants and nerve agents. And health care providers need to be innovative and creative and find different ways to implement pain medication delivery, using methods like steroid injections and epidural catheters.
Providers must also work harder to encourage those who do develop addictions to enlist in rehabilitation, and they should involve more frequently other specialists in crafting and carrying out treatment plans, especially pain management doctors and psychologists.
Most importantly, all providers need to look in the mirror and ask themselves if we are being good stewards of prescribing practices, or if we are part of the problem we see in the news.” (J)

“The USC-Brookings Schaffer Initiative for Health Policy’s Jason N. Doctor and Michael Menchine also say that emergency rooms are playing a significant role in the opioid crisis. First, emergency room visits are a notable source of the over-prescription of opioids—often with deadly consequences. Narcotic overdose is the eighth leading cause of death within one week of an emergency room visit.
Additionally, emergency rooms are often on the frontlines of treating those harmed by the epidemic. Currently, there are over 300,000 estimated annual emergency department visits for opioid overdose.
To address the crisis, Doctor and Menchine explain Congress and the Trump administration will have to focus on reducing population exposure to opioids, creating demand for safe and effective treatments, and the effective use of emergency departments. They recommend that the current administration and Congress fund additional resources to emergency rooms, including:
The development of opioid dependence screening tools for the emergency department;
Training to emergency department staff on how to address potentially opioid dependent individuals in an ethically neutral manner;
The expansion of referral sources for outpatient addiction specialty clinics (particularly for uninsured patients or those with Medicaid insurance);
Reduced administrative barriers to becoming a Buprenorphine prescriber; and
The development of a financial reimbursement model for prescription opioid screening or treatment in emergency room settings.” (K)

“Doctors at some of the country’s largest hospital chains admit they went overboard with opioids to make people as pain-free as possible.
Now the doctors shoulder part of the blame for the country’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain…
Opioid addiction is a reality that has been completely disconnected from where it often starts — in a hospital….
So the nation’s largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.
“We will treat the pain, but you should expect that you’re going to have some pain. And you should also understand that taking a narcotic so that you have no pain really puts you at risk of becoming addicted to that narcotic,” Schlosser tells patients.
Besides issuing the uncomfortable warning, sparing use of opioids also takes more work on the hospital’s part — trying nerve blocks and finding the most effective blend of non-narcotics. Then after surgery, the nursing staff has to stick to it. If someone can get up and walk and cough without doubling over, maybe they don’t need potentially addictive drugs, or at least not high doses of them.” (L)

Five Big Ideas to Confront the Opioid Crisis
1. Stop overprescribing
2. Treat opioid addiction as the public health crisis that it is
3. Stop the deaths
4. Guarantee Access to Treatment
5. Invest in data and knowledge” (M)

“In New York City, opioid addiction treatment is sharply segregated by income, according to addiction experts and an analysis of demographic data provided by the city health department. More affluent patients can avoid the methadone clinic entirely, receiving a new treatment directly from a doctor’s office. Many poorer Hispanic and black individuals struggling with drug addiction must rely on these highly regulated clinics, which they must visit daily to receive their plastic cup of methadone…
This is what opioid addiction recovery is like for more than 30,000 patients enrolled in New York City’s approximately 70 methadone-based treatment programs, which provide medication-assisted treatment, counseling and other social services. Hundreds of thousands of patients across the country are enrolled in similar programs, which often receive government funding and are covered by Medicaid in New York.
For more than 40 years, methadone was the most effective method for people addicted to heroin to keep their cravings in check. But in 2002, the Food and Drug Administration approved another medication to treat opioid addiction: buprenorphine, sold most widely in a compound called Suboxone. Both methadone and buprenorphine are extremely effective in keeping recovering users from relapsing, according to medical research, but Suboxone is engineered to reduce the possibility of abuse and overdose. Crucially, the medication can be prescribed in doctors’ offices and then taken at home.
Many hoped that buprenorphine could mean an end to the daily hurdles to receiving treatment for tens of thousands of patients: no additional commute, no security check, no waiting, no line for the plastic cup.
But today in the city, that is primarily true only for middle-class or upper-middle-class patients seeking help with their addiction.” (N)

“In May 2016, Taylor Weyeneth was an undergraduate at St. John’s University in New York, a legal studies student and fraternity member who organized a golf tournament and other events to raise money for veterans and their families.
Less than a year later, at 23, Weyeneth, was a political appointee and rising star at the Office of National Drug Control Policy, the White House office responsible for coordinating the federal government’s multibillion dollar anti-drug initiatives and supporting President Donald Trump’s efforts to curb the opioid epidemic. Weyeneth would soon become deputy chief of staff.
Weyeneth’s brief biography offers few clues that he would so quickly assume a leading role in the drug policy office, a job recently occupied by a lawyer and a veteran government official. His only professional experience after college and before becoming an appointee was working on Trump’s presidential campaign.
Weyeneth’s ascent from a low-level post to deputy chief of staff is due in large part to staff turnover and vacancies. The story of his appointment and remarkable rise provides insight into the Trump administration’s political appointments and the troubled state of the drug policy office.” (O)

(A) Trump declared an opioids emergency. Then nothing changed, by BRIANNA EHLEY, https://www.politico.com/story/2018/01/11/opioids-epidemic-trump-addiction-emergency-order-335848
(B) How can we solve the opioid crisis?, by Sarah Karlin-Smith, https://www.politico.com/video/2017/11/02/how-can-we-solve-the-opioid-crisis-064251
(C) The Public and the Opioid-Abuse Epidemic, by Robert J. Blendon, and John M. Benson, http://www.nejm.org/doi/full/10.1056/NEJMp1714529#t=article
(D) America’s Opioid Crisis Looks a Lot Like Big Tobacco Spats of Yesteryear, by Bill Meagher, https://www.thestreet.com/story/14397159/1/how-opioid-crisis-of-today-resembles-big-tobacco-lawsuits-battles.html
(E) Judge urges action on ‘100 percent manmade’ opioid crisis, by ANDREW WELSH-HUGGINS, http://abcnews.go.com/Health/wireStory/judge-urges-action-100-percent-manmade-opioid-crisis-52235186
(F) The statistics don’t capture the opioid epidemic’s impact on children, by CAROL LEVINE, https://www.statnews.com/2018/01/02/opioid-epidemic-impact-children/?utm_source=STAT+Newsletters&utm_campaign=073963a01b-First_Opinion&utm_medium=email&utm_term=0_8cab1d7961-073963a01b-150519373
(G) Stop Calling it an Opioid Crisis—It’s a Heroin and Fentanyl Crisis, by JEFFREY A. SINGER SHARE, https://www.cato.org/blog/stop-calling-it-opioid-crisis-its-heroin-fentanyl-crisis
(H) Could Jeff Sessions’ Marijuana Ruling Make the Opioid Crisis Even Worse?, by MARY BROPHY MARCUS, https://www.menshealth.com/health/jeff-sessions-marijuana-policy-opioid-crisis
(I) A Seven-Step Plan for Ending the Opioid Crisis, by Michael R. Bloomberg, https://www.bloomberg.com/view/articles/2018-01-10/a-seven-step-plan-for-ending-the-opioid-crisis
(J) Dr. Jacquelyn Corley To fix the opioid crisis, doctors like me may have to let patients be in pain, https://www.nbcnews.com/think/opinion/fix-opioid-crisis-doctors-me-may-have-let-patients-be-ncna836141
(K) The far-reaching effects of the US opioid crisis, by Brennan Hoban, https://www.brookings.edu/blog/brookings-now/2017/10/25/the-far-reaching-effects-of-the-us-opioid-crisis/
(L) Hospitals Brace Patients For Pain To Reduce Risk Of Opioid Addiction, by BLAKE FARMER, https://www.npr.org/sections/health-shots/2018/01/09/576584541/hospitals-brace-patients-for-pain-to-reduce-risk-of-opioid-addiction
(M) CONFRONTING OUR NATION’S OPIOID CRISIS, https://assets.aspeninstitute.org/content/uploads/2018/01/AHSG-Final-Report-2017_compressed-2.pdf
(N) Opioid Addiction Knows No Color, but Its Treatment Does, by JOSE A. DEL REAL, https://www.nytimes.com/2018/01/12/nyregion/opioid-addiction-knows-no-color-but-its-treatment-does.
(O) Trump’s response to opioid epidemic includes 24-year-old helping lead drug policy office, by Robert O’Harrow Jr., http://www.chicagotribune.com/news/nationworld/politics/ct-trump-drug-policy-office-20180113-story.html

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In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

“This winter’s flu season is turning into a “moderately severe” one that might get worse because of an imperfect vaccine and steady cold weather, flu experts and public health officials said this week…
About 80 percent of cases are of the H3N2 strain, which caused many hospitalizations and deaths this year in Australia, where winter comes in July and August.
“H3N2 is a bad virus,” Dr. Jernigan said. “We hate H3N2.”
Compared to H1N1, the other seasonal Type A strain, and to B strains that usually arrive late in the season, H3N2 tends to kill more of the very young and very old, he said…
The H3N2 component of Australia’s flu shot was reported to be only 10 percent effective at preventing infection and is the same as in North American shots. But both Dr. Jernigan and Dr. Fauci said they expected to see roughly 30 percent effectiveness when data is collected at season’s end, in part because more healthy people get their shots.
The vaccine mismatch was not caused by a genetic shift in the circulating flu, as happens in some years, but by changes in the “seed virus” used in the vaccine; as it grew in eggs, it picked up mutations foreign to human flu.” (A)

“The flu season is straining resources at hospitals nationwide with the Centers for Disease Control and Prevention reporting the flu is widespread in 46 states. Some hospitals are setting up emergency tents to handle the high volume of patients while others are dealing with a shortage of IV bags after Hurricane Maria cut power to manufacturing plants in Puerto Rico.
IV bags hold the medicines and fluids administered by IV and now nurses and doctors are being forced to find other ways to care for their patients, reports CBS News’ Michelle Miller.
In the intensive care unit at Massachusetts General Hospital, nurse Hannah Owens-Pike uses Gatorade to combat dehydration. It now takes her four times as long to administer treatment that would normally be delivered intravenously. Hospital staffers are forced to conserve supplies. (B)

Here is what you should know about this flu season:
1. It’s shaping up to be one of the worst in recent years
2. This season’s flu vaccine is likely to be less effective than in previous years
3. You should get the flu shot anyway
4. Basic precautions may spare you and your family from days in bed
5. Don’t mistake flu symptoms for those of a common cold (C)

“You’re going to be really annoyed, if after spending 12 hours waiting in the ER, we just say “you have the flu, go home.” But that’s all we’ll be able to say to you. Because we cannot cure the flu. It is a virus. We can try to make you feel better. But lots of the things we do for the flu, you can do at home. Flu care mostly consists of supportive measures like fluids and rest and over-the-counter medications.
Ibuprofen (like Motrin) usually makes people feel better than Tylenol. “Prescription strength” ibuprofen is 800 mg (four over-the-counter 200 mg tablets) taken every eight hours, and that’s the best thing to take, unless you have an ulcer. Take with food or milk or an antacid.
If you cannot hold anything down, we can give you IV fluids and anti-nausea medicine.
You may have heard of Tamiflu, the flu medicine. Tamiflu reduces symptoms by an average of one to one and a half days and can have side effects. It is also ineffective after 24 to 48 hours of symptom onset. We will give it to you if we think you really need it, but if we don’t give it, trust us that it’s because it’s not going to help you.
Do not request a Z-Pack. Antibiotics do not help a virus and risk giving you antibiotic-associated diarrhea, and you don’t want that…
There are other ways to get help beyond an unsatisfying trip to the emergency department. Here are our best suggestions:
Call your primary care doctor. Often your primary care doctor can offer advice over the phone or get you in her office. Give your doctor a chance to take care of you!
Urgent care centers: Wait times are considerably less at urgent care centers than emergency departments, and they’re usually able to estimate times over the phone. Many can administer all the treatments described above, even the IV fluids and X-rays.
Telemedicine: Consider finding out if your insurance pays for telemedicine services. This is a perfect use of telemedicine, and you won’t be exposing anyone else to the flu.” (D)

““What should you do if you have the flu?
Often the only response required for treating the flu is rest and staying hydrated, according to the CDC, since most people who get the flu do not need medical care or medication. Infected individuals should not go to the emergency room unless they have very severe symptoms, including being unable to eat, having trouble breathing, and severe vomiting.
Alas, Antibiotics are only helpful for treating bacterial infections, but influenza is caused by a virus.
People who are at high risk for complications — young children, people 65 and older, pregnant women and people with certain medical conditions — may consider taking an antiviral treatment to shorten the length of the illness. If you are in that group, contact your health care provider, the CDC suggests.
Should you go to work if you feel up to it?
Another important measure to take if you have the flu is staying home. More than one-quarter of American workers admit to going to work when they are sick, largely because of their work load, according to a survey released Tuesday by the public health nonprofit organization NSF International.
Being a martyr at work is highly discouraged by the CDC. “Stay away from others as much as possible to keep from infecting them,” the CDC said. “If you must leave home, for example to get medical care, wear a face mask if you have one, or cover coughs and sneezes with a tissue.” (E)

“At the Palomar Medical Center near San Diego, the new year ushered in a brutal flu season.
“The day came when we had extended waits in the emergency department up to eight or nine hours for a patient to be seen,” said Michelle Gunnett, emergency room nursing director. “We need to figure out other space to see patients.”
That space ended up being a triage tent set up right outside the ER.” (F)

“We are not prepared. Our current vaccines are based on 1940s research. Deploying them against a severe global pandemic would be equivalent to trying to stop an advancing battle tank with a single rifle. Limited global manufacturing capacity combined with the five to six months it takes to make these vaccines mean many people would never even have a chance to be vaccinated. Little is being done to aggressively change this unacceptable situation. We will have worldwide flu pandemics. Only their severity is unknown.
The only real solution is a universal vaccine that effectively attacks all influenza A strains, with reliable protection lasting for years, like other modern vaccines. Although the National Institutes of Health has publicly declared developing a vaccine a priority, it has only about $32 million this year specifically for such research. The Biomedical Advanced Research and Development Authority, the other federal agency responsible for developing and making available new vaccines for emergency response, has in fiscal year 2017 only a single project for $43 million supporting game-changing influenza vaccines….
The next few weeks will highlight how ill prepared we are for even “ordinary” flu. A worldwide influenza pandemic is literally the worst-case scenario in public health — yet far from an unthinkable occurrence. Unless we make changes, the question is not if but when it will come.” (G)

“In 2009, former President Barack Obama released a photo getting his H1N1 (swine flu) vaccine. President Gerald Ford got his swine flu vaccine back in 1976 on television. Plenty of governors and senators also release photos of their influenza vaccinations. In 2010, Obama officially declared Dec. 5-11 as National Influenza Vaccination Week. “I encourage Americans to get vaccinated this week if they have not yet done so, and to urge their families, friends, and co workers to do the same,” he wrote.” (H)

“Did President Donald Trump Get the Flu Shot? Some public health experts are hopeful that he will—and that he’ll talk about it” (I)

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.

(A) Already ‘Moderately Severe,’ Flu Season in U.S. Could Get Worse, by DONALD G. McNEIL Jr., https://www.nytimes.com/2018/01/08/health/flu-season-cdc.html
(B) Hospitals struggle to battle peak flu season amid widespread IV bag shortage, https://www.cbsnews.com/pictures/notable-deaths-in-2017/
(C) What You Need To Know About This Year’s Flu Season, by BARBARA FEDER OSTROV, https://www.npr.org/sections/health-shots/2018/01/09/576772534/facing-down-flu-5-things-to-know-now
(D) What to Do if You Have the Flu, by Dara Kass and Brian Thomas Fletcher, http://www.slate.com/articles/health_and_science/medical_examiner/2018/01/how_to_handle_the_flu.html
(E) The flu costs Americans $10.4 billion in medical expenses and another $7 billion in lost productivity, by Kari Paul, https://www.marketwatch.com/topics/journalists/kari-paul
(F) Hospitals grapple with brutal flu season that could get even worse, by JONATHAN LAPOOK, https://www.cbsnews.com/news/hospitals-grapple-with-brutal-flu-season-that-could-get-even-worse/
(G) We’re Not Ready for a Flu Pandemic, MICHAEL T. OSTERHOLM and MARK OLSHAKERJAN, https://www.nytimes.com/2018/01/08/opinion/flu-pandemic-universal-vaccine.html?_r=0
(H) Did President Donald Trump Get the Flu Shot?, by Alexandra Sifferlin, http://time.com/5093600/president-trump-flu-shot/
(I) Did President Donald Trump Get the Flu Shot?, http://global.breaking.quwa.org/news/did-president-donald-trump-get-the-flu-shot

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“wreck and rejoice” – has consequences. BTW, there is a congressional exemption from ObamaCare

“Here are the five ways President Trump could weaken the ACA in 2018….easing ACA regulations on association health plans and extending short-term coverage….Continue outreach cuts….Target the essential health benefits…4. Allow insurers to leave counties….5.Not support ACA stabilization bills. The Alexander-Murray market stabilization bill and a reinsurance proposal from Sen. Susan Collins, R-Maine, have received support from Senate leadership, but unless President Trump pressures the House to support the measures, they have a much lower chance of passing into law.” (A)

“After a year in which Obamacare’s fate hung by a thread, 2018 is likely to feature fewer mortal threats. But the next 12 months could still be a tumultuous period as insurers, customers and elected officials react to major changes to the law by the Trump administration and the Republican Congress….
The new tax bill eliminates the individual mandate, a key pillar of the ACA. Trump’s White House is pursuing new regulations that could undermine Obamacare plans with cut-rate alternatives. Some states are struggling to attract insurers, a problem that’s carried over from the Obama era. Republicans are still debating whether to give the ACA a bipartisan tune-up or purposefully “let Obamacare fail,” as the president has put it. And nobody is sure what surprises the year might bring.” (B)

“President Donald Trump is predicting that Democrats and Republicans will “eventually come together” on a new health care plan for the country.
Sending a Twitter post early Tuesday from his Florida resort, Trump said “the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) Obamacare.”
Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) ObamaCare, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!” (C)

“Surpassing nearly everyone’s expectations, more than 8.8 million Americans signed up for ObamaCare this year. Simple marketplace demand prevailed over convoluted Republican attempts to deter enrollment and repeal ObamaCare. With generous federal subsidies offering significant savings, Obama’s signature healthcare law may have provided the best economic deal for millions of Americans, transcending politics.
Even Trump’s own supporters could not resist signing up.
In an ironic twist of events, more than 80 percent of Americans enrolling in ObamaCare this year come from states that Trump won in the 2016 election. The top four states with the largest number of sign-ups, namely Texas, Georgia, Florida, and North Carolina all hail from the deep red South and all went for Trump.
In retrospect, this should not come as a surprise. The same voters who propelled Trump to an Electoral College victory, mainly the older white voters in rural America and whites without a college degree, are the same groups of people who stand to benefit the most from ObamaCare.
This is especially the case in rural areas where healthcare costs are higher due to fewer insurance companies offering coverage. Less competition leads to higher premiums, an issue ObamaCare specifically remedies with federal subsidies. Trump’s own supporters therefore put their economic self-interest over their allegiance to party politics. They chose the cheapest health insurance available that offset these unfair costs.
They chose ObamaCare.” (D)

“President Trump and his allies in Congress failed in their effort to “repeal and replace” Affordable Care Act (ACA), so they have settled upon a “wreck and rejoice” strategy instead…
If the repeal of the mandate was supposed to be a dagger in the heart of Obamacare, it missed its mark. The heart of Obamacare still beats. The insurance exchanges remain in place, as does the expansion of Medicaid coverage.
The Congressional Budget Office estimates, however, that there will be 4 million fewer people will have insurance coverage by 2019, and by 2027, there will be 13 million fewer enrollees. As a result, insurance premiums for enrollees will be 10 percent higher by 2027 than they would have been otherwise.
Whether or not the repeal of the mandate wrecks the ACA, it is hardly cause for rejoicing. Not long ago the President was bragging about creating a “beautiful” replacement for Obamacare that would provide broader and better coverage.
That thought, however “beautiful” it was in its conception, has now been abandoned in favor of maiming the ACA by any means possible.
Repeal of the ACA’s enrollment mandate will be especially harmful with respect to contraceptive coverage. The CBO’s report does not give us a breakdown of the 13 million people who, by 2027, will not be enrolled in an insurance plan, but many of them will be younger people who elect to drop their coverage once the tax penalty for non-enrollment is lifted.
And many of them will be women who might otherwise benefit from the ACA’s “contraceptive mandate.” (E)

“States are likely to get more power to set Obamacare coverage requirements under a Department of Health and Human Services proposed rule likely to be finalized in early 2018.
Comprehensive essential health benefits (EHBs) that health plans are required to cover under the Affordable Care Act are generally based on the largest small business health plans operating in each state. Under the proposed rule, state insurance regulators in the 39 states that use the federal HealthCare.gov exchange could choose categories of benefits from health plans offered in other states, or they could come up with their own set of benefits with approval from the HHS.
States that are struggling to maintain individual market coverage under the ACA may try to reduce premiums by looking for plans in other states where benefits are skimpier….
“The EHB flexibility allows so much mixing and matching that it could be used to patch together a plan that is not representative of employer-based coverage as required by the statute,”… “We do not want to go back to days when individual coverage was inferior to group coverage,” as was the situation before the ACA took effect in 2014,… (F)

“Health insurance companies that stuck with providing individual coverage under the Affordable Care Act will divvy up the spoils next year thanks to departures of rivals Aetna, Anthem, UnitedHealth Group and Humana from key markets.
With less competition and the benefit of double-digit percentage price increases, Centene, Cigna, Oscar Health and Blue Cross and Blue Shield plans stand to benefit from the ACA in 2018 .
Oscar enrolled more than 250,000, or a 150% increase in individual customers in its individual plans , the company said last week. Regional health plans like Medica, Kaiser Permanente and others also are expected to grow in 2018 from the ACA.
Nationally, enrollment was ahead of expectations and not far off last year’s total even though the Donald Trump administration cut the sign-up period in half. More than 8.8 million Americans signed up to individual coverage for 2018 via the ACA’s exchanges or slightly below last year’s 9.2 million.
“Given the generally healthy appearance of marketplace enrollment, carriers like Centene who doubled down on serving the subsidized population are probably feeling reassured,” said Katherine Hempstead, who directs the Robert Wood Johnson Foundation’s work on health coverage issues. “For those who count on the off exchange market as well the outlook is a little less clear.”” (G)

“Before Congress left Washington for the year, Republicans finally made good on their determination to knock big holes in the Affordable Care Act, crippling its requirement that most Americans carry health insurance and leaving insurers without billions of dollars in promised federal payments.
At the same time, public support for the perennially controversial law has inched up to around its highest point in a half-dozen years. Nearly 9 million people so far have signed up for ACA health plans for 2018 during a foreshortened enrollment season, far surpassing expectations.
This dual reality puts the sprawling ACA – prized domestic legacy of the Obama era, whipping post of the Trump administration – at a new precipice, with its long-term fate hinging on the November midterm election certain to consume Washington once the New Year begins. If Democrats win a majority in either chamber of Congress, the law would be protected; a Republican sweep could further embolden repeal attempts…
“To those who believe – including Senate Republican leadership – that in 2018 there will not be another effort to repeal and replace Obamacare – well you are sadly mistaken,” Sen. Lindsey O. Graham, R-S.C., tweeted last week.
Graham’s vow was a rejoinder to Senate Majority Leader Mitch McConnell, R-Ky., who suggested in an NPR interview that “we’ll probably move on to other issues.” He also noted that the chamber’s already-slender Republican majority will shrink to one senator once the Democratic winner of a special election in Alabama is sworn in next month.
McConnell reiterated his intention to try to coax the Senate early in the year to adopt two measures, promised to a crucial Senate Republican moderate in exchange for her support of the massive tax overhaul enacted last week, that would help cushion ACA insurance marketplaces….(H)

“President Donald Trump has said the GOP’s tax bill “essentially repealed” Obamacare. He’s wrong — the Affordable Care Act (ACA) will survive 2018 at least semi-intact. It’s probably not going to thrive, though.
The worst-case scenario for the law — a partial repeal paired with deep cuts to Medicaid — was averted after the GOP couldn’t muster 50 votes for a series of bills in the Senate. The election of Doug Jones in Alabama and signals from Senate Majority Leader Mitch McConnell suggest another bite at that particular apple is not forthcoming. But that was only a partial escape. The Trump administration’s treatment of the individual insurance market has ranged between neglect and sabotage. It cut funding for ACA advertising and enrollment-assistance efforts, shortened the enrollment period, and stopped payment of an insurer subsidy. That was enough to help boost premiums — though it doesn’t appear to have hurt enrollment as much as some might have expected. The toxic cherry on top was the GOP tax bill’s effective repeal of the ACA’s individual mandate. This will be a blow starting in 2019. Fewer people will sign up for insurance on the exchanges (and in general). The people that do sign up and stick with their insurance will tend to be sicker. That will make exchange participation increasingly expensive and risky for insurers. The CBO projects mandate repeal will cut 13 million from insurance rolls by 2025.” (I)

“Republicans have been asking themselves what they’ll turn to next, after their tax overhaul wraps up. If they repeal the Affordable Care Act’s individual mandate, there’s a good chance the answer will be health care — whether they like it or not.
What they’re saying: President Trump has said several times that he wants to take another crack at repeal-and-replace after the tax bill. GOP leaders in the House and Senate have not echoed that plan. But if Republicans do end up repealing the individual mandate, Insurance markets will begin to feel the effects quickly, leading to almost immediate nationwide upheaval that will be impossible to ignore — especially in an election year.
This year saw a lot of chaos — insurers pulling out of markets, coming back in, changing their premiums at the last minute — due in large part to changes that would pale in comparison to something on the scale of repealing the individual mandate.
“I think next year will be even crazier” if the coverage requirement goes away, the Kaiser Family Foundation’s Larry Levitt says.
The timing: The disruption caused by repealing the individual mandate would start early next year and intensify again just before next year’s midterm elections.
The Senate’s tax bill would eliminate the ACA’s penalty for being uninsured, starting on Jan. 1, 2019. That might seem like a long way away, but it’s not.
Insurers will start deciding this coming spring whether they want to participate in the exchanges in 2019 — and if so, where. Without the mandate, insurers would likely begin to pull back from state marketplaces early next year, likely leaving many parts of the country with no insurance plans to choose from.
Insurers will then have to finalize their 2019 premiums next fall. Those rates would likely be substantially higher (10% higher, on average, according to the Congressional Budget Office) without the mandate in place — and that news would hit just before next year’s midterms.
The bottom line: All this fallout would be impossible to ignore, putting more pressure on Congress to return to health policy whether it wants to or not — and reopening all the same internal divisions that have stymied every other health care bill.” (J)

“As I wrote earlier this year, Republicans want less government, Democrats want more. Substantive reforms cannot do both. If lawmakers wish to pass substantive reforms, and the argument that it’s necessary to do so is sound, they must realize they will not be able to find enough common ground to proceed, even now with repeal of the individual mandate. No policy crisis is big enough to bridge the ideological gap between Democrats and Republicans.
As our healthcare system’s struggles worsen, the president is certainly right that Congress will be forced back to the negotiating table.
But any hopes of lawmakers crafting a “great new HealthCare plan” with serious bipartisan support are misplaced. Whatever solutions ultimately pass will either be on a smaller scale or determined entirely by the party in control.” (K)

“There is a relatively simple solution, if states are willing to embrace it. They can fill the gap by passing their own individual mandates that apply within their borders, keeping the essential elements of the Obamacare system intact as far as their jurisdiction extends. In fact, states could make Obamacare work better than it had before, applying a larger penalty than the relatively small one that people have so far faced for skipping out on their responsibility to keep themselves covered. This would encourage more young and healthy people to enter the insurance market, thereby restraining premiums and boosting enrollment.
There would be challenges. States would have to move very quickly to reassure insurers before the 2019 enrollment season. New mandates would have to pass through state legislatures, a tough and perhaps lengthy political process. States that do not collect income taxes would have to devise some minimally onerous way to charge penalty payments. Political and ideological opposition means that many Republican-led states are more likely to choose chaos than they are to fix Obamacare. The result would be a further bifurcation of the U.S. health-care system into states that prioritize expanding coverage and those that prioritize attacking Obamacare.
But the bottom line remains: Not everyone must suffer from Congress’s irresponsibility. States can fix the problem Republicans are creating. They should do so, now.” (L)

“Republicans have no health care message — none. More talk about free market solutions to health insurance costs — such as tort reform, allowing people to buy insurance across state lines, and so on — does nothing to address the acute problem that households are facing as they attempt to balance their monthly budgets.
Worse, every time the Republicans have tried to pass a bill in Congress specifically addressing health care, they have failed, miserably.
Structurally, the Republicans still have an advantage in the 2018 midterms. They only have eight Senate seats up for re-election, as opposed to the Democrats’ 25. And the congressional district maps drawn after 2010 still favor the GOP, even if some incumbents face tough races in districts that voted for Hillary Clinton. Tax cuts will help, as will Trump’s other policy successes. And the radicalism of the left’s so-called “Resistance” will alienate some voters.
But all of those factors together may not outweigh health care as a deciding issue in the midterm elections. Voters, at least beyond the primary phase, are not interested in punishing failure as much as in finding solutions. Democrats are appealing to the electorate with the false promise of other people’s money.
Republicans have no alternative yet. Unless they can find a way to address the urgent needs of patients, they will lose Congress, and deservedly so.” (M)

“Congressional Republicans will open their 2018 legislative agenda wrangling over a politically dicey and very familiar issue: Obamacare.
Moderates want to bolster the Affordable Care Act, especially in the face of possible new hikes in premiums for insurance consumers.
Conservatives want to take another shot at killing the 2010 health care law, even though the GOP’s attempts to do that consumed much of 2017 and ended in an embarrassing failure…
This time around, Republicans will face more pressure to act, especially in the Senate. That’s because Senate Majority Leader Mitch McConnell, R-Ky., promised a key GOP moderate he would push for passage of two bills designed to stabilize Obamacare and keep premiums down in the individual insurance market…
McConnell originally promised Collins that he would push the two bills through Congress last month. But that plan faced stiff opposition in the House, where Speaker Paul Ryan, R-Wis., said he was not bound by McConnell’s agreement.
Conservatives in the House are staunchly opposed to any legislation that would prop up Obamacare. They say the Alexander-Murray proposal is a bailout for insurance giants.
Other Republicans say they should turn back to repealing Obamacare all together and replacing it with a GOP alternative. McConnell has suggested he would only revisit a repeal-and-replace bill if he was sure it would pass the Senate — a steep challenge given that Republicans will only control 51 votes chamber starting Wednesday, when a newly elected Democrat, Doug Jones of Alabama, is sworn in.” (N)

“Workers would be allowed to band together to buy health insurance under a proposed rule released Thursday by the Department of Labor.
The proposed rule was issued in response to an executive order by President Trump, which would allow associations of workers to purchase cheaper health insurance that’s not subject to the same rules as plans under ObamaCare.
By allowing groups of people to purchase plans not subject to ObamaCare’s rules for coverage, however, critics say the move could allow insurers to sell plans that do not cover pre-existing conditions or offer certain “essential health benefits.”
The requirement that insurers cover people with pre-existing conditions was a hallmark of the Affordable Care Act, and a provision that is broadly popular.” (O)

“Congress has no choice but to revisit the issue. The growth in spending on health-care entitlements like Medicaid and Medicare threatens to overwhelm the Treasury, starving the federal government of the funds it needs to pay for everything else, including education, welfare and national defense.
Sen. McConnell said last month that any bill to reform entitlements will need to be bipartisan. He’s right that getting Republicans and Democrats to cooperate is the most sustainable way to pass such legislation. But with the “resistance” in full swing, bipartisanship may be a pipe dream. On the other hand, if Republicans want to tackle health care alone, they will need to take a different approach from the one that failed in 2017…
There is thus not much to gain by spending 2018 trying to replace ObamaCare’s insurance exchanges. Republicans can instead liberalize the individual insurance market by restoring flexibility that states lost under ObamaCare. A good strategy would be to build on bipartisan efforts such as those from Sens. Lamar Alexander and Patty Murray.” (P)

“So, pulling the individual mandate out of Obamacare does not kill Obamacare. It will probably destabilize it a bit. But destabilizing Obamacare without replacing it is no good. It essentially speeds it up, by driving the country to the point where there is no working insurance sector for individual, non-employer, markets.
A crumbling private insurance sector will not help. Instead, it will legitimize calls for a government takeover of health insurance — the so-called “single-payer” healthcare system…
The question, therefore, is how to overcome the barriers at which repealing and replacing Obamacare fell last year? The answer is to embrace the safety net that Democrats and Sen. Susan Collins, R-Maine, demand, but separate it from the insurance market. Deregulate insurance, delink it from employment, and allow purchases across state lines. Create real competition in healthcare provision and the way it is paid for.
Then, separately, create better government-backed insurance products for those who can’t get affordable insurance in the market. This isn’t a small-government ideal, but it’s better than a single-payer nightmare.” (Q)

“Obamacare isn’t failing. Again.
That report instead finds that the Obamacare market has continued “stabilizing,” and that insurers are “regaining profitability” despite continued political uncertainty over the health-care law.
It also found that the pool of Obamacare customers, while less healthy as a group than before the law took effect, showed no signs of becoming sicker in the latter part of 2017.
“Data suggest that insurers in this market are on track to reach pre-[Affordable Care Act] individual market performance levels,” said the report, prepared by analysts from the Kaiser Family Foundation.
The report, comes on the heels of surprisingly strong enrollment on the federal Obamacare marketplace during the recently concluded open sign-up season.
The Trump administration, which opposes Obamacare, had taken a series of steps that experts believed would markedly depress the number of sign-ups for individual health plans this year.
President Donald Trump also has repeatedly said that Obamacare is “failing,” and needs to be substantially replaced with new health-care legislation.” (R)

“A book detailing the first year of President Trump’s time in office claims he floated the idea of covering all Americans through Medicare and had little interest in repealing Obamacare.
“All things considered, he probably preferred the notion of more people having health insurance than fewer people having it,” Michael Wolff writes in Fire and Fury: Inside the Trump White House. “He was even, when push came to shove, rather more for Obamacare than for repealing Obamacare.”
Trump also reportedly asked his aides aloud, “Why can’t Medicare simply cover everybody?”…
The late Roger Ailes, who was chairman and CEO at Fox News, told Wolff that “no one in the country, or on earth, has given less thought to health insurance than Donald.”” (S)

“As President Trump meets with congressional Republican leaders at Camp David this weekend, he’s going to be faced with tough decisions about his second-year agenda. Here are some items he could consider.
First, end the congressional exemption from ObamaCare. The biggest disappointment of 2017 was the failure of Republicans to fully repeal ObamaCare. It is a huge disgrace, and will likely hurt them as they seek reelection in 2018. The best way to motivate them to repeal this law is to force them to live under the law like every other American, something they haven’t had to face since President Obama ordered an illegal carve-out for members of Congress and their staffs more than four years ago. The best part is that this is something the president doesn’t need to wait for Congress to do. He can do this himself with the stroke of a pen, by simply directing the Office of Personnel Management to overturn its ruling of late 2013 approving members of Congress and their staffs to purchase health insurance through the District of Columbia small business exchange, which allowed them an employer’s subsidy they were not meant to receive.” (T)

“The chances of repealing ObamaCare this year are fading further, with top Republicans saying they hardly discussed repeal of the law during a Camp David retreat last weekend focused on their 2018 agenda….
A source familiar with the conversations at Camp David confirmed that ObamaCare repeal was hardly discussed, except for Senate Majority Leader Mitch McConnell (R-Ky.) saying that he did not want to do a partisan bill like ObamaCare repeal or entitlement reform through the fast-track process of reconciliation this year.
ObamaCare repeal has largely fallen off the GOP agenda for 2018, in part due to the realities of a narrower Senate majority than one that already failed to pass a repeal bill. Reopening the divisive issue in an election year would also be tough.” (U)

“You can scour the rest of the text, but I don’t think you’ll find any other mentions of the individual mandate. Notice at the bottom that the effective date is after this year, so folks still need to have health insurance in 2018 or pay the penalty.
The method by which the mandate was repealed is interesting: they merely zeroed out the penalty for noncompliance. In the ACA, it’s called a penalty, but the Supreme Court ruled it a tax. So the “tax” now has a rate of “zero percent” and a bottom levy of “$0.” But because Obamacare is still on the books, some future Congress under Democrat control could easily raise the tax or penalty back to where it was, or even higher — and use reconciliation to do so!” (V)

(A) 5 actions Trump can take to undermine the ACA in 2018, by Leo Vartorella, https://www.beckershospitalreview.com/hospital-management-administration/5-actions-trump-can-take-to-undermine-the-aca-in-2018.html
(B) Obamacare barely survived 2017. How’s 2018 look?, by BENJY SARLIN, https://www.nbcnews.com/politics/white-house/obamacare-barely-survived-2017-how-s-2018-look-n832936
(C) President Trump Says Republicans and Democrats Will ‘Come Together’ to Replace Obamacare, http://time.com/5079455/trump-obamacare-republicans-democrats/
(D) Transcending politics, Trump’s core supporters love ObamaCare, by EUGENE GU, http://thehill.com/opinion/healthcare/366801-Transcending-politics-Trumps-core-supporters-love-ObamaCare
(E) CRIPPLING OBAMACARE HURTS POOR PEOPLE AND WOMEN ABOVE ALL, by ROBERT WALKER, http://www.newsweek.com/crippling-obamacare-hurts-poor-people-and-women-above-all-758311
(F) Proposed Obamacare Rule Could Weaken Benefits, by Sara Hansard, https://www.bna.com/proposed-obamacare-rule-b73014473614/
(G) Insurers Divvy Up Spoils For Sticking With Obamacare In 2018 by Bruce Japsen , https://www.forbes.com/sites/brucejapsen/2017/12/26/insurers-divvy-up-spoils-for-sticking-with-obamacare-in-2018/#715e8a8b467a
(H) The future of Obamacare now linked to midterm election in 2018, by AMY GOLDSTEIN, http://www.pressherald.com/2017/12/25/aca-future-is-linked-to-midterm-election-in-2018/
(I) Obamacare Will Survive in 2018, by Max Nisen, https://www.bloomberg.com/gadfly/articles/2017-12-27/obamacare-will-survive-in-2018
(J) GOP may have no choice but to try health care again after taxes, by Sam Baker, https://www.axios.com/gop-may-have-no-choice-but-to-try-health-care-again-after-taxes-2513940879.html
(K) A comprehensive bipartisan solution to healthcare reform is probably impossible, by Emily Jashinsky, http://www.washingtonexaminer.com/a-comprehensive-bipartisan-solution-to-healthcare-reform-is-probably-impossible/article/2644412
(L) States can fix Republicans’ Obamacare mess, https://www.washingtonpost.com/opinions/states-can-fix-republicans-obamacare-mess/2018/01/01/19590388-dabb-11e7-b1a8-62589434a581_story.html?utm_term=.c380426f1edb
(M) POLLAK: Republicans Will Lose in 2018 If They Fail to Solve Health Insurance Crisis, by JOEL B. POLLAK, http://www.breitbart.com/big-government/2018/01/02/pollak-republicans-can-win-in-2018-if-they-solve-health-insurance-crisis/
(N) Republicans face a fresh fight over Obamacare: Repeal it or repair it?, by Deirdre Shesgreen, https://www.usatoday.com/story/news/politics/2018/01/02/republicans-face-fresh-fight-over-obamacare-repeal-fix/997008001/
(O) Trump offers new rule going after ObamaCare, by NATHANIEL WEIXEL, http://thehill.com/policy/healthcare/367393-Trump-offers-new-rule-going-after-ObamaCare
(P) Republicans Can’t Avoid ObamaCare in 2018, by Avik Roy, https://www.wsj.com/articles/republicans-cant-avoid-obamacare-in-2018-1514938806
(Q) Happy New Year! Now repeal and replace Obamacare, http://www.washingtonexaminer.com/happy-new-year-now-repeal-and-replace-obamacare/article/2644914
(R) Obamacare insurers see better financial performance in 2017, ‘no sign of market collapse’, by Dan Mangan, https://www.cnbc.com/2018/01/04/obamacare-health-insurers-see-improved-financial-performance-in-2017.html
(S) Michael Wolff: Trump had little interest in repealing Obamacare, floated ‘Medicare for All’, by Kimberly Leonard, http://www.washingtonexaminer.com/michael-wolff-trump-had-little-interest-in-repealing-obamacare-floated-medicare-for-all/article/2645078
(T) A 2018 agenda for President Trump, by JENNY BETH MARTIN, http://thehill.com/opinion/white-house/367793-a-2018-agenda-for-president-trump
(U) ObamaCare repeal fades from GOP priorities list in new year, by PETER SULLIVAN, http://thehill.com/policy/healthcare/368223-obamacare-repeal-fades-from-gop-priorities-list-in-new-year
(V) The Trump Tax Cuts and the Obamacare Mandate ‘Repeal’, by Jon N. Hall, http://www.americanthinker.com/articles/2018/01/1_9_2018_14_3.html#ixzz53pt56pUl

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“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

“People in public health hate H3N2 flu seasons, like the one gripping most of North America right now. So do folks who work in hospitals and in the care facilities that look after the elderly.
To put it flatly, H3N2 is the problem child of seasonal flu.
It causes more deaths than the other influenza A virus, H1N1, as well as flu B viruses. It’s a quirky virus that seems, at every turn, to misbehave and make life miserable for the people who contract it, the scientists trying to keep an eye on it, and the drug companies struggling to produce an effective vaccine against it.
“H3 viruses dwarf the contribution of H1 to overall epidemic burden [of influenza] in terms of hospitalizations, care facility outbreaks, deaths. I think uniformly in public health we dread H3N2 epidemics over and above those due to H1N1,” said flu expert Dr. Danuta Skowronski, an epidemiologist with the British Columbia Center for Disease Control.
Dr. Daniel Jernigan, head of the influenza division at the Centers for Disease Control and Prevention, concurred. “We just know, over the last several years, when we have an H3 season, it’s unfortunately causing worse disease. But also the vaccine’s effectiveness [targeting it] is not as high as the other components. And so for that reason, even though you’ve been vaccinated, you still can get infected,” ….. “People born before 1968 were not imprinted with an H3N2 virus. So they may have increased susceptibility [to it] as well as, by virtue of their age, have greater vulnerability, just through complications. So that could be totally independent of whether the virus itself is more virulent or not,”…(A)

“Influenza activity increased sharply again in this week’s FluView report. The number of jurisdictions experiencing high activity went from 21 states to 26 states and New York City and the number of states reporting widespread activity went from 36 to 46.” (B)

“We are arguably as vulnerable—or more vulnerable—to another pandemic as we were in 1918. Today top public health experts routinely rank influenza as potentially the most dangerous “emerging” health threat we face. Earlier this year, upon leaving his post as head of the Centers for Disease Control and Prevention, Tom Frieden was asked what scared him the most, what kept him up at night. “The biggest concern is always for an influenza pandemic…[It] really is the worst-case scenario.” So the tragic events of 100 years ago have a surprising urgency—especially since the most crucial lessons to be learned from the disaster have yet to be absorbed.” (C)

“This is just the seasonal flu we’re talking about. It’s not that big of a deal, right?
It is, actually. Seasonal flu epidemics cause three to five million cases of severe disease each year worldwide, leaving 300,000 to 500,000 dead, according to the World Health Organization. In the US, flu forces 140,000 to 710,000 people into hospitals and causes 12,000 to 56,000 deaths annually. The hardest hit are children, the elderly, and people with compromised immune systems.” (D)

“California is reeling from a particularly severe surge in cases of the flu—with pharmacies running out of medicine, packed emergency rooms and a rising death toll.
State health officials say that 27 people younger than 65 have died of the flu in California since October. That’s compared to three the same time last year, The Los Angeles Times reports.
According to health officials, there’s no region of the state where people were being spared from the flu.
At UCLA Medical Center in Santa Monica, the emergency room saw more than 200 patients on at least one day, mostly because of the flu…
Though the flu killed three Californians by this time last year, 68 people had died from it by the end of February, according to state data.
Still, many doctors say the recent surge in flu cases have been unusually severe…
National health officials predict the flu vaccine may only be about 32 percent effective this year. But most people in California and the rest of the country are catching a particularly dangerous strain of influenza that the vaccine typically doesn’t work well against.” (E)

“Methodist Dallas Medical Center announced Sunday night that all non-emergency patients were being diverted to other hospitals due to an influx of patients with the flu. (Published Monday, Jan. 8, 2018)
Methodist Dallas Medical Center says they at “critical capacity” and that all non-emergency patients are being re-routed to urgent care facilities or other hospitals so that they can continue to handle emergencies.
The increase in patient load is largely due to an influx of patients with the flu, the hospital said. Methodist Dallas Medical Center said they are still accepting trauma patients and that anyone who arrives at the hospital needing emergency treatment will receive treatment.
“Consistent with federal and state laws, Methodist Dallas Medical Center is currently re-routing non-emergency patients due to high volumes of patients with flu-like symptoms. This measure is so we can still take care of emergency patients such as trauma, stroke, and those transferred by ambulance. We take this very seriously because we want to be able to treat anyone in need anytime.
During the period while Methodist Dallas is re-routing patients, we encourage anyone having non-emergent symptoms to seek care at an urgent care facility or through their primary care physician.” (F)

Clean Hands Prevent Cold & Flu
http://globalhandwashing.org/wp-content/uploads/2017/02/Clean-Hands-Prevent-Cold-Flu-slide-deck.pdf

Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions
https://www.cdc.gov/flu/protect/whoshouldvax.htm

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.

(A) ‘The problem child of seasonal flu’: Beware this winter’s virus, by HELEN BRANSWELL, https://www.statnews.com/2018/01/08/flu-virus-h3n2/?utm_source=STAT+Newsletters&utm_campaign=0db0193a7b-MR&utm_medium=email&utm_term=0_8cab1d7961-0db0193a7b-150519373
(B) Situation Update: Summary of Weekly FluView Report, https://www.cdc.gov/flu/weekly/summary.htm
(C) How the Horrific 1918 Flu Spread Across America, by John M. Barry, https://www.smithsonianmag.com/history/journal-plague-year-180965222/
(D) Looks like a rough flu season ahead. Here are answers to ALL your flu questions, by Beth Mole, https://arstechnica.com/science/2017/12/this-years-flu-season-is-upon-us-and-it-looks-bad-heres-what-you-should-know/
(E) Severe flu in California brings medicine shortages, kills 27, by Christopher Carbone, http://www.foxnews.com/health/2018/01/07/severe-flu-in-california-brings-medicine-shortages-kills-27.html
(F) Dallas Methodist Hospital at ‘Critical Capacity,’ Re-Route Non-Emergency Flu Patients, https://www.nbcdfw.com/news/local/Dallas-Hospital-Turns-Away-Non-Emergency-Patients-Due-to-Flu-Activity-468264083.html

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The Trump administration “… hasn’t done squat” about the Opioid Crisis – but is prosecuting marijuana offenses & fired all HIV/AIDS Commission members

“We wonder what it will take to shake the faith of Trump’s fans. His subservience to Russia’s ongoing cyber-invasion? Nope. His relentless assaults on the integrity of our law enforcement and intelligence agencies? Nope. Shooting someone in broad daylight on Fifth Avenue? Probably nope.
But his failure to tackle the opioid epidemic — his big talk and dearth of meaningful action — might conceivably dampen their ardor.
This prescription drug plague has hit their world hard. More than 100 people die each day from opioid ODs; the victims are disproportionately young and middle-aged working-class men in small towns and rural communities — the heart of Trump’s constituency. The worst epidemic state is West Virginia, which Trump won by 43 points. He spoke to their despair when he promised to alleviate it. During the campaign he repeatedly referenced the opioid scourge: “If I win, I’m going to stop it …. We’re gonna spend the money. We’re gonna get that habit broken.”
And not long ago, as president, he vowed to cure the “worst drug crisis in American history” by declaring “a national emergency,” a legal designation that automatically frees up massive federal funds. He promised action that would be “really tough, really big, really great.”
He hasn’t done squat.” (A)

“The average American life expectancy ticked downward for the second straight year in 2016, on the back of surging drug overdose deaths, according to data released Thursday by the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention. And while the nation hasn’t experienced a back-to-back drop in life expectancy since the 1960s, the CDC says the opioid crisis is shaping up to extend this decline for a third consecutive year, a milestone that hasn’t been seen since the Spanish flu pandemic in 1918.
U.S. life expectancy fell to an average of 78.6 years in 2016, dropping 0.1 for the second year in a row, according to the CDC report. The slide was driven by higher death rates among young and middle-aged Americans, with those aged 25-34 experiencing the largest increase. The death rate among Americans aged 65 and older actually inched downward between 2015 and 2016.
The overall decline in longevity came as drug overdose deaths exploded in 2016 to a total of 63,600, around 42,000 of which involved opioids, according to CDC data. Although these numbers have been rising steadily since 1999, the 21 percent jump in deaths over 2015 was the largest annual increase so far. Drug overdose deaths involving synthetic opioids like fentanyl and fentanyl analogs have increased an average of 88 percent each year from 2013 to 2016, helping to drive the surge.” (B)

“Over the past few years, economists have struggled to explain why so many people appear to be dropping out of the workforce. The most telling measure of that is the labor-force participation rate—which measures the percentage of the population that is employed or actively looking for work—which now sits around 62.7 percent. That’s low by historical standards. For example, between 1986 and 2001, labor-force participation grew fairly steadily, to between 65 and 67 percent….
The economist Alan Krueger’s work has shown that there’s a striking relationship between these missing workers and increasing opioid addiction. According to an analysis done by Krueger, over the past 15 years, labor-force participation among prime-age workers has declined the most in U.S. counties where opioids prescriptions are the most plentiful. He is sure to mention that cause and effect aren’t clear: It’s hard to say whether addiction breeds joblessness, or vice versa. “Regardless of the direction of causality, the opioid crisis and depressed labor force participation are now intertwined in many parts of the U.S.,” Krueger writes.” (C)

The U.S. foster care system is overwhelmed, in part because America’s opioid crisis is overwhelming. Thousands of children have had to be taken out of the care of parents or a parent who is addicted.
Indiana is among the states that have seen the largest one-year increase in the number of children who need foster care. Judge Marilyn Moores, who heads the juvenile court in Marion County, which includes Indianapolis, says the health crisis is straining resources in Indiana.
“We’ve gone from having 2,500 children in care, three years ago, to having 5,500 kids in care. It has just exploded our systems,” Moores says.
While laws in all U.S. states require that child welfare agencies make “reasonable efforts” to reunify parents with their children, Moores says that process can be especially traumatic for children whose parents often relapse.
She says that more legal consideration should be paid to the child’s rights and safety and that “right now, that balance does not tip legally in favor of the child.”
Earlier this year, President Trump declared the opioid epidemic a public health emergency. But that designation “didn’t come with money,” Moores says. “And that is sadly what the necessity is.” She says reform is needed, and it should focus on “how much in the way of resources should be devoted to trying to reunify children with parents who cannot conquer their addiction.”” (D) (E)

“In “Communities in Crisis: Local Responses to Behavioral Health Challenges,” a report from Manatt Health, we highlight how cities and counties are responding to the opioid crisis and untreated mental illness by developing community-driven programs that connect individuals to treatment and social support services. Successful initiatives are creating systems of care that bridge multiple programs to provide coordinated services to individuals with SUD.
Here are five elements of successful local programs: 1.Collaboration and alignment of local resources. 2.Establishment of a holistic system of care. 3.Navigation across care settings. 4.Community engagement and advocacy. SUD that combines traditional drug court services with behavioral health counseling and treatment. 5.Leveraging both public and private financing.” (F)

“UPMC Hamot’s new Pregnancy Recovery Center looks a lot like the orthopedic office it is replacing on the third floor of 300 State St.
The walls of the office’s waiting room remain covered with nautical drawings and pictures, while the exam rooms still look the same. But starting Jan. 2, the office will see expectant women who are addicted to opioids instead of people with broken bones and damaged joints.
“Our goal is to get these women into treatment as early in their pregnancy as possible and reduce the number of babies born who require neonatal withdrawal,” said Emma Mack, R.N., the center’s outreach coordinator.
Erie County’s opioid epidemic has spurred local hospitals to increase their efforts to help pregnant women who are addicted to these drugs. Saint Vincent Hospital opened its Growing Hope program in September 2016 and now Hamot is creating its program, which is based on a similar one Magee Women’s Hospital of UPMC started in 2014.
Pregnant women with addictions are referred to these programs by their obstetrician-gynecologist, an emergency department physician or a drug-treatment facility. An initial appointment is scheduled and an effort is made to switch the patient to the treatment drug Subutex to wean the woman off opioids and control her withdrawal symptoms.” (G)

“Rochester Regional Health expects by April to open a crisis center at the St. Mary’s Campus in the city. The crisis center will evaluate and treat people coping with an acute behavioral or chemical dependency problem, and arrange follow-up care.
The urgent care model is appropriate for someone who is not a danger to themselves or others, or in the midst of an overdose, said Kathy McGuire, senior vice president of behavioral health and home and community services for Rochester Regional.
“Somebody having an anxiety attack would have gone to the emergency room,” she said. “People go to the emergency room when they’re intoxicated. People who haven’t taken their medication in a bunch of days, they need to talk to somebody and get back on their meds.”
Planning started in 2014, and the idea originally was to treat just mental health episodes. But increasing opioid abuse forced a second look.
“The more the opioid crisis came into full view, the more we said there’s such a tie between chemical dependency and mental health,” McGuire said. “We should be thinking about how we should be using this urgent care center to deal with this crisis as well.” (H)

“The paramedics find them everywhere – slumped over car steering wheels, barely breathing in doughnut shop bathrooms or dead in derelict apartments and expensive mansions.
For the Cataldo Ambulance Service crews outside Boston on the front lines of the U.S. opioid epidemic, the flood of overdose calls is a grim daily reality, despite expanded access to overdose reversal drugs.
“When I started, this was a rare thing. You did one or two here and there. Now, we do quite a few,” said Dave Franklin, 44, a supervisor at the private service that contracts with cities who has worked in the field for more than 20 years.
In Massachusetts, EMS opioid overdose calls hit 20,978 in 2016, up from 8,389 in 2013, according to a state report.
Amid wider use by bystanders and police of naloxone, a drug that reverses overdose symptoms, state figures showed a small drop in opioid deaths in the first nine months of 2017 compared with 2016. But Franklin does not yet see a turning point….
At the ambulance, he checks to make sure there is enough naloxone. They carry more than double the amount they once did because stronger opioids mean that multiple doses of naloxone are often required for someone who is barely breathing.” (I)

“The Chicago Urban League recently issued a paper titled “Whitewahed: The African-American Opioid Epidemic,” outlining the drug’s toll on that community: African-Americans make up 15 percent of the state’s population but account for 24 percent of opioid-related deaths.
At the same time, the researchers said, African-Americans are less likely to get help because Cook County, home to about 2 out of 3 black Illinoisans, has a relative scarcity of clinics providing buprenorphine — the medication many experts believe is among the most effective treatments.
Stephanie Schmitz Bechteler, a co-author of the report, said those grim facts have been missing from the public deliberation over heroin, which often focuses on white users in suburban and rural areas.
“On the one hand, the change in narrative has brought a broader awareness to the issue, but it has come at the expense of the comprehensive set of people who are affected by this,” she said.” (J)

“Based on his latest study, Dartmouth-Hitchcock’s Chief of Surgery Dr. Richard Barth is offering surgeons specific guidelines for post-surgery prescriptions for pain-relieving opioids.
Barth said as a surgeon he wanted to see if there was something he could do to curb the opioid crisis.
Many states, including New Hampshire, have adopted laws that prohibit doctors from prescribing more than a seven-day supply of opioids — but a seven-day supply can range from 20 pills to 80 pills, Barth said.
“I know I prescribe opioids for patients that I operate on I was just wondering if I could do that better and optimize that and help to diminish this epidemic,” Barth said. “The Surgeon General has said if doctors keep prescribing more pills than are actually needed, then this crisis is going to go on unabated.”
The study was published in the Journal of the American College of Surgeons on Dec. 15 and is based on a series of studies Barth conducted at Dartmouth-Hitchcock.
According to the peer-reviewed Journal article, this is the first time specific guidelines have been proposed for prescribing opioids after surgery patients are discharged from the hospital.
The studies took a look at patients who did not have issues with chronic pain, and so were not on opioid medications on a regular basis.” (K)

“New Jersey Gov. Chris Christie says the U.S. finally addressed the HIV/AIDS crisis in the 1980s because affected Americans paraded down the streets of Washington and other major cities, saying it was time for power brokers to take the epidemic seriously.
It’s time to start marching again, he recently told Congress — this time to erase widespread stigma that is holding back the fight against an opioids epidemic that kills about 100 people per day in the U.S.
“We will have seen that we’ve begun to remove the stigma of this disease when the people who are impacted are willing to show their face and march and demand, from their government, a response,” said Mr. Christie, a Republican who led President Trump’s commission on opioids addiction. “They don’t march today because they are ashamed to march, because they don’t want to be identified.”
As federal and state leaders try to catch up with the opioids crisis, analysts say too many people still treat drug addiction as a personal failing instead of a disease and that it’s keeping too many Americans from getting the help they need.
Only 1 in 10 people who need treatment for a substance use disorder are getting it — a ratio that would be unfathomable for conditions such as diabetes or kidney cancer…
Mr. Christie’s commission called for a nationwide awareness campaign to focus on the dangers of opioid use and to remove stigma attached to addiction.
Congress is still debating how much funding to devote to the campaign and overall fight, but in the meantime, it is investigating what role opioid manufacturers may have played in aggressively marketing pain pills or downplaying their addictive qualities in the late 1990s and early 2000s.” (L)

“That should be a wake-up call for the Trump administration, which has talked a fine game about the opioid epidemic but done too little to address it. A far greater sense of urgency is needed to address what has become one of the gravest public-health threats to the United States in living memory…
It would be a mistake to see the fall in life expectancy as part of a broad decline in American public health. Infant mortality continues to drop, and death rates from heart disease, cancer, flu, diabetes, kidney disease and other causes are mainly flat or falling. Rather, the main culprits are known as “diseases of despair” — especially drug overdoses and suicide. And the main victims are men, especially working-class young and middle-aged men, for whom the overdose death rate is twice that of women.
Mindful of the soaring toll, President Trump appointed a presidential commission on combating drug addiction and the opioid crisis, which recommended last summer that the president declare a national emergency, as he has pledged to do. That would have freed up funding from the national Disaster Relief Fund. Instead, in October he declared a public-health emergency, a lesser designation and one that has not unlocked game-changing amounts of federal dollars.
At the highest levels, the administration’s response to the crisis has been sluggish, characterized by boastful rhetoric but stagnant funding. Mr. Trump has spoken of the government producing “really tough, really big, really great advertising,” as if a Nancy Reagan just-say-no approach were adequate to the task of tackling a complex public-health scourge. He said the administration would crack down on the synthetic opioid fentanyl, manufactured in China, and endeavor to develop nonaddictive painkillers as an alternative to opioids. But where is the funding?” (M)

“Democrats, especially in the Senate, have called for including some opioid funding in any major government funding package. Some Republicans whose states have been hit hardest by the crisis, like Sens. Rob Portman of Ohio and Shelley Moore Capito of West Virginia, have also called for more spending.
There are already small signs that Congress might sign off on more spending in 2018. Kellyanne Conway, the White House adviser who has been leading a kind of “opioids cabinet,” told STAT she is working with the Office of Management and Budget on a request for more funds. Outside groups have also said there may be more motivation to pass funding to address the opioid crisis in an election year.
House Energy and Commerce Committee Greg Walden of Oregon told STAT he is hoping to work on an opioids measure in the new year. And Rep. Tom MacArthur (R-N.J.), who is co-chair of the Bipartisan Task Force to Combat the Heroin Epidemic, said the group delivered a host of new policy proposals to Republican leadership that are aimed at addressing the crisis. He said that effort should also be paired with new funding.” (N)

“In the wake of the opioid crisis, hospitals in the Nashville area are now warning patients that they may have to deal with some pain following surgery or other procedures.
David Alfery, M.D, a Nashville anesthesiologist and part of the working group at the regional consulting firm Health Trust, told Nashville Public Radio that patients have developed unrealistic expectations about post-surgical pain management. As a result, the Hospital Corporation of America-owned TriStar Centennial Medical Center has implemented a new protocol that requires surgeons to have difficult conversations with their patients about opioid addiction.
Mike Schlosser, M.D., chief medical officer for HCA National Group, told the publication that he explains to patients that he will treat their pain but they should expect some level of discomfort because narcotics that eliminate all pain will put them at risk for addiction.
It’s not easy for physicians to strike a balance between meeting the pain management needs of patients and preventing addiction. Many doctors have not had training on effective pain management, and may be confused by guidelines to reduce prescriptions for powerful painkillers. Another wrinkle is that patient satisfaction surveys, like the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), include pain management questions.” (O)

“There are a series of actions that need to be taken if we are going to affect the opioid crisis.
Educate physicians, nurses, pharmacists, medical students, residents and the public on the treatment of acute and chronic pain.
Pharmaceutical companies need to recognize their role in creating this crisis and work with the medical profession to address it.
Educate patients regarding treatment approaches to both acute and chronic pain.
Implement a group model for patients who present to primary pain clinics with complaints of chronic pain. This model is well suited to educate patients regarding the clinic’s approach to the use of opioid analgesics, central and peripheral mechanisms involved in pain, non-medication approaches to pain and empowerment to support each other in dealing with chronic medical conditions involving pain.
Encourage physicians to take the online training in the use of buprenorphine, an often lifesaving medication.” (P)

“The Justice Department has awarded over $70 million during 2017 to help fight the opioid crisis nationwide and set up drug courts. It has directed U.S. Attorneys to aggressively prosecute drug dealers, and just last week established a new office to help oversee the implementation of Justice Department initiatives and coordinate with state and local law enforcement.
Violent drug dealers are not the only ones being prosecuted. As the number of drug-related deaths escalates, law enforcement officials are under growing pressure to prosecute and lock up not only criminal drug dealers, but also doctors, pharmaceutical company officials, and even friends and family of the victims if they’ve aided in an overdose death….
It is unlikely that the opioid crisis will be brought under control in the near future. Prevention and compassionate treatment are important, but even more crucial is for law enforcement to use the proven tools it has at its disposal to prosecute those responsible for the deaths of thousands of Americans. (Q)

“While some insurers have become part of the solution, many continue to contribute to the epidemic. Four out of five heroin users start with prescription painkillers, and our commonwealth and country have been flooded with unnecessary, highly addictive prescription opioids.
Despite no change in reported pain levels, sales of prescription opioids quadrupled form 1999 to 2014 and continue at a staggering pace. In 2015, U.S. doctors wrote 300 million pain prescriptions — and insurance companies approved nearly every single one of them, typically without questioning the need or offering meaningful coverage for alternatives.
Insurers decide which treatments and medications we can afford and which will remain out of reach due to high prices. Aetna is helping by eliminating its copay for Narcan and by limiting the amount of opioid medication approved for short-term pain. Independence Blue Cross also has acted to limit opioid prescriptions. More insurers should take similar steps.
It’s long past time to change the corporate cultures of pharmaceutical and insurance companies so that they value the health and safety of their customers as much as their bottom lines.” (R)

“Gov. Chris Christie still hopes to make tackling opioid addiction his signature accomplishment as he prepares to leave office on Jan. 16.
Christie announced grants in excess of $35 million Tuesday for qualified health care providers to care for patients with severe opioid use disorders, pregnant and postpartum mothers, and older adults with opioid dependencies…
“To ensure treatment is successful, it is essential that systems of care join seamlessly to treat the whole individual,” Christie said in a press release. “This funding supports the type of integration of behavioral and primary health care I envisioned when transferring the Division of Mental Health and Addiction Services from the Department of Human Services to the Department of Health.”” (S)

“Attorney General Jeff Sessions on Thursday rescinded a trio of memos from the Obama administration that had adopted a policy of non-interference with marijuana-friendly state laws.
The move essentially shifts federal policy from the hands-off approach adopted under the previous administration to unleashing federal prosecutors across the country to decide individually how to prioritize resources to crack down on pot possession, distribution and cultivation of the drug in states where it is legal.
While many states have decriminalized or legalized marijuana use, the drug is still illegal under federal law, creating a conflict between federal and state law. Thursday’s announcement is a major decision for an attorney general who has regularly decried marijuana use as dangerous.” (T)

“The remaining members of the Presidential Advisory Council on HIV/AIDS were fired en masse this week.
Months after a half-dozen members resigned in protest of the Trump administration’s position on health policies, the White House dismissed the rest through a form letter.
The notice “thanked me for my past service and said that my appointment was terminated, effective immediately,” said Patrick Sullivan, an epidemiologist at Emory University who works on HIV testing programs. He was appointed to a four-year term in May 2016.
The council, known by the acronym PACHA, has advised the White House on HIV/AIDS policies since its founding in 1995. Members, who are not paid, offer recommendations on the National HIV/AIDS Strategy, a five-year plan responding to the epidemic.
The group is designed to include “doctors, members of industry, members of the community and, very importantly, people living with HIV,” said Scott Schoettes, a lawyer with the LGBT rights organization Lambda Legal. “Without it, you lose the community voice in policymaking.”” (U)

(A) Trump on the opioid crisis: Big talk, little action (big surprise), by Dick Polman, https://whyy.org/articles/trump-opioid-crisis-big-talk-little-action-big-surprise/
(B) Opioid Crisis Could Be Biggest Hit To U.S. Life Expectancy In A Century, CDC Says, by Nick Wing, https://www.huffingtonpost.com/entry/opioid-deaths-life-expectancy_us_5a3bfdeee4b0b0e5a7a09e0b
(C) The Opioid Crisis Comes to the Workplace, by GILLIAN B. WHITE, https://www.theatlantic.com/business/archive/2017/12/workers-dying-overdoses/549008/
(D) The Foster Care System Is Flooded With Children Of The Opioid Epidemic, by SCOTT SIMON, https://www.npr.org/2017/12/23/573021632/the-foster-care-system-is-flooded-with-children-of-the-opioid-epidemic
(E) Ohio Child Advocates: Opioid Crisis Straining Foster Care, https://www.usnews.com/news/best-states/ohio/articles/2017-12-21/ohio-child-advocates-opioid-crisis-straining-foster-care
(F) Five key elements of successful local initiatives to combat the opioid crisis, byJonah Frohlich, Chris Cantrell, http://managedhealthcareexecutive.modernmedicine.com/managed-healthcare-executive/news/five-key-elements-successful-local-initiatives-combat-opioid-crisis
(G) Opioid crisis spurs Erie hospitals to help addicted pregnant women, by David Bruce, http://www.goerie.com/news/20171225/opioid-crisis-spurs-erie-hospitals-to-help-addicted-pregnant-women
(H) Rochester Regional opening crisis center to apply urgent care model to mental health, Patti Singer, http://www.democratandchronicle.com/story/news/2017/12/23/rochester-regional-mental-health-crisis-opioid/978831001/
(I) Boston-Area Paramedics on Front Lines of U.S. Opioid Crisis, https://www.usnews.com/news/us/articles/2017-12-22/boston-area-paramedics-on-front-lines-of-us-opioid-crisis
(J) Black victims of heroin, opioid crisis ‘whitewashed’ out of picture, report finds, http://www.chicagotribune.com/news/local/breaking/ct-met-heroin-crisis-african-american-impact-20171220-story.html
(K) NH surgeon offers opioid-prescription guidelines to try to help curb opioid crisis, By MEGHAN PIERCE, http://www.unionleader.com/health/nh-surgeon-offers-opioid-prescription-guidelines-to-try-to-help-curb-opioid-crisis-20171226
(L) Chris Christie calls for campaign to take opioid epidemic seriously and break stigma of addiction, https://www.washingtontimes.com/news/2017/dec/25/opioid-epidemic-fighters-aim-break-addiction-stigm/
(M) America’s opioid epidemic saps life expectancy while the White House sleepwalks, https://www.washingtonpost.com/opinions/americas-opioid-epidemic-saps-life-expectancy-while-the-white-house-sleepwalks/2017/12/26/ac997b2c-e697-11e7-a65d-1ac0fd7f097e_story.html?utm_term=.74284d88bd2a
(N) 3 legislative battles to watch in 2018, by Erin Mershon, https://www.statnews.com/2018/01/02/legislative-battles-2018/
(O) Nashville hospitals take aim at opioid crisis by adjusting approach to pain management, by Paige Minemyer, https://www.fiercehealthcare.com/healthcare/opioid-crisis-drug-addiction-hospital-corporation-american-lifepoint-health?mkt_tok=eyJpIjoiTkdNeE9HVTJPV1V4Wm1SaSIsInQiOiJoZlg5SXN6dzJPc2lHa3FFckV3UElIT0dVREtRR3Fid3hwSmhjQjVyZzdMZ2VIMkcxc1YrYVRPYVNyTUtxaVNBQzlVcjVtdDZ5RFo5Y1wvQStTV1dYZ1k0UTlSam1EY2VQeCtocXM4YUkyQVkrSFZmZm4yNmZ4WittY25rWGRUdjAifQ%3D%3D&mrkid=654508
(P) The U.S. Opioid Crisis: How Can We Remedy?, by Walker Ray, MD and Tim Norbeck , https://www.forbes.com/sites/physiciansfoundation/2018/01/03/the-u-s-opioid-crisis-how-can-we-remedy/#140cd2803768
(Q) The opioid crisis, by Alfred S. Regnery, https://www.washingtontimes.com/news/2018/jan/4/opioid-crisis-is-public-health-emergency-but-its-a/
(R) Opioid crisis: Drug companies, health insurers must step up, by JOSH SHAPIRO, https://www.newsitem.com/articles/opioid-crisis-drug-companies-health-insurers-must-step-up/
(S) Christie grants $35M toward opioid treatment, by Vince Calio, http://www.njbiz.com/article/20180103/NJBIZ01/180109968/christie-grants-35m-toward-opioid-treatment
(T) Sessions nixes Obama-era rules leaving states alone that legalize pot, by Laura Jarrett, https://www.fiercehealthcare.com/healthcare/antibiotic-resistance-research-superbugs-alternative-therapies?mkt_tok=eyJpIjoiTVRFMU4ySTROemM0WWpVNSIsInQiOiJPYWdRdHZEaUZWSXZrVEluUWE5OTRuZVVoMTJGdmhaMVdJbFFUVUtYZjFHUzJmRFI0ZWlyWkVBeWdkUmJCQ2NOVmY3OTlyZTdZUzl0eEc5Zk12N2U5VW1ld0tseFF4YVJsRjFHenI4R25VZ0ZQUG1hNjdOamdjY2crSTZDYmNmTiJ9&mrkid=654508
(U) Trump administration fires all members of HIV/AIDS advisory council, by Ben Guarino, https://www.washingtonpost.com/news/to-your-health/wp/2017/12/29/trump-administration-fires-all-members-of-hivaids-advisory-council/?utm_term=.fcc415cc633c

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In 2018 the CVS-Aetna “Unicorn” will buy a mega-hospital system and become a very disruptive patient “ownership” trajectory

2017’s headline is the rapid transformation of the American health care system with disruptive hybrid private sector mergers, mega-hospital system mergers creating horizontally and vertically super-sized systems, and major capital expansion investment by academic medical centers to retain national and regional “anchor” supremacy.
And the explanation by pundits of the various competing trajectories.
My approach is to curate an annotated synopsis and let the readers reach their own conclusions.
So get started! (And Happy New Year!)
JMM

“The U.S. health care system is begging for disruption. It costs way too much ($3.3 trillion last year) and delivers too little value. Hundreds of millions of Germans, French, English, Scandinavians, Dutch, Danish, Swiss, Canadians, New Zealanders, and Australians get comparable or better health services for half of what we pay. For most Americans, care is not only expensive but is also fragmented, inconvenient, and physically inaccessible, especially to the sickest and frailest among us.
It should come as no surprise, then, that when titans of our private, for-profit health care sector — like Aetna, CVS, UnitedHealth Group (UHG), and DaVita — strike out in new directions, stakeholders react with fascination and excitement. Could this be it? Is free-market magic finally bringing Amazon-style convenience, quality, and efficiency to health care? Are old-guard institutions, like hospitals and nursing homes, on the verge of extinction?” (A)

“CVS Health said on Sunday that it had agreed to buy Aetna for about $69 billion in a deal that would combine the drugstore giant with one of the biggest health insurers in the United States and has the potential to reshape the nation’s health care industry…
The merger comes at a time of turbulent transformation in health care. Insurers, hospitals and pharmacy companies are bracing for a possible disruption in government programs like Medicare as a result of the Republicans’ plan to cut taxes. Congress remains at an impasse over the future of the Affordable Care Act, while employers and consumers are struggling under the weight of rising medical costs, including the soaring price of prescription drugs. And rapid changes in technology have raised the specter of new competitors — most notably Amazon.
A combined CVS-Aetna could position itself as a formidable figure in this changing landscape. Together, the companies touch most of the basic health services that people regularly use, providing an opportunity to benefit consumers. CVS operates a chain of pharmacies and retail clinics that could be used by Aetna to provide care directly to patients, while the merged company could be better able to offer employers one-stop shopping for health insurance for their workers.
But critics worry that customers could also find their choices sharply limited. The deal risks leaving patients with less choice of where to get care or fill a prescription if those with Aetna insurance are forced to go to CVS for much of their care.” (B)

“Ana Gupte, PhD, a senior healthcare services analyst at Leerink Partners, told CNBC she could see Walmart and health insurer Humana joining forces to compete in the shifting healthcare landscape.
“Humana and Walmart have been in a very tight relationship for six, seven years,” she said, and Humana members already receive deals on prescription copays at Walmart pharmacies. Increasing competition and the threats posed by CVS’ deal with Aetna may be enough to push Walmart to consider buying Humana, according to the report.
Anthem, Cigna and Walgreens may also be among the healthcare companies interested in striking a deal, according to Dr. Gupte.” (C)

“In another example of the blurring boundaries in the health care industry, UnitedHealth Group, one of the nation’s largest insurers, said on Wednesday that it is buying a large physician group to add to its existing roster of 30,000 doctors.
UnitedHealth’s Optum unit will acquire the physician group from DaVita, a large for-profit chain of dialysis centers, for about $4.9 billion in cash, subject to regulatory approval. DaVita operates nearly 300 clinics across a half-dozen states, including California and Florida.
With the purchase, UnitedHealth is increasingly moving into the direct delivery of medical care…
The potential threat of new competitors like Amazon entering the pharmacy business and technology companies delivering medical care through cellphones has led former adversaries to become partners, driving insurers to team up with hospitals and doctors’ groups. They are seeking to deliver care in novel ways, outside the expensive setting of a hospital…
Even if insurers succeed in lowering medical costs as a result of the new ventures, economists and other experts warn that shareholders, not consumers, could benefit unless the lower costs yield lower prices for coverage. There must be sufficient competition among insurers for consumers to benefit, Professor Garthwaite said. (D)

“Health care Goliaths are cutting out the middleman. The American health care system is full of intermediaries chasing after a share of the industry’s profit, often by gaming one another. UnitedHealth’s $4.9 billion purchase of a physicians group from DaVita is the latest example of trying to cut costs by eliminating such links in the chain.
The health care system in the United States is akin to one of Rube Goldberg’s zany cartoon contraptions. America spends far more than other countries on treating or preventing ailments, yet with mediocre outcomes. It also ranks worst among 11 industrialized countries in the percentage allocated to administration, the time doctors need to receive insurer approval for treatments, and how long patients spend disputing costs, according to a 2014 Commonwealth Fund study.
The multiplicity of players — drugmakers, doctors, pharmacies, pharmacy benefit managers, insurers, wholesalers and hospitals — means lots of hands trying to grab money from other participants. (E)

“U.S. health insurer Humana and two private-equity firms agreed to buy home health-care and long-term care operator Kindred Healthcare on Tuesday for about $4 billion, the latest expansion by a U.S. health insurer into patient care….
Humana, the fourth-largest U.S. health insurer, will pay $800 million for a 40 percent stake in Kindred at Home, which will contain Kindred’s 40,000 caregivers that serve about 130,000 patients daily.” (F)

“Catholic Health Initiatives (CHI) and Dignity Health have signed a definitive agreement to combine ministries and create a new, nonprofit Catholic health system. The combination brings together two leading health systems, allowing the organizations to expand their mission of service and create a healthier future for people and communities across 28 states….
The new health system will include more than 700 care sites and 139 hospitals, offering people and communities access to quality care delivered by approximately 159,000 employees and more than 25,000 physicians and other advanced practice clinicians. The organizations are geographically complementary with no overlap across hospital service areas.” (G)

“Two major hospital systems are in talks about a possible merger that would create the largest U.S. owner of hospitals, as a series of deals shape up to further consolidate control of the health-care landscape.
Ascension and Providence St. Joseph Health, both nonprofits, are talking about combining, according to people familiar with the discussions. A deal would create an entity of unprecedented reach, with 191 hospitals in 27 states and annual revenue of $44.8 billion… (H)

“Looking to grow their brands and health services, several Catholic-owned hospital operators have announced or are reportedly involved in merger talks….
The more than 300 Catholic hospitals involved in these deals mean fewer acquisition targets for HCA, Tenet, Community and other for-profits. These investor-owned giants are already seeing their hospital admissions deteriorate in the move to value-based care that emphasizes payments to outpatient providers and doctor’s offices to make sure more care is given upfront before it reaches an inpatient facility. In Tenet’s third quarter, for example, “same hospital patient revenue decreased 2.3%” which “reflects a 2.2% decrease in adjusted admissions,” the company said last month.
Tenet is evaluating options for the entire chain of 77 hospitals and 460 outpatient centers including possible sale. “We have and we will continue to review, analyze and pursue all options to enhance shareholder value,” Tenet’s Ronald Rittenmeyer, executive chairman and CEO said in November. (I)

“Franklin, Tenn.-based Community Health Systems completed its 30-hospital divestiture plan Nov. 1. Now, the company expects to sell another group of its hospitals with combined revenue of $2 billion, Chairman and CEO Wayne Smith said during a third quarter earnings call.
To improve its finances and reduce its heavy debt load, CHS put a turnaround plan into place last year. As part of the initiative, the company announced in early 2017 that it intended to sell off 30 hospitals. In August, CHS extended its divestiture plan. The company said it would sell a group of hospitals with combined revenue of $1.5 billion in addition to the 30 hospitals already announced….
“Our goal is to emerge from this process with a sustainable group of hospitals that are positioned for long-term success and growth,” he said.” (J)

“Carolinas HealthCare System, the Charlotte region’s dominant hospital chain, will partner with UNC Health Care of Chapel Hill to form a medical giant – one that leaders of the two systems predict will expand access to care, improve quality and boost the state’s economy…
It marks a major development for Carolinas HealthCare, Charlotte’s largest employer. The new system would run more than 50 hospitals and employ more than 90,000 people, making it one of the nation’s largest hospital chains.
But experts in hospital consolidation cautioned Thursday that deals like these tend to drive up health care costs. That’s because larger systems have more leverage to negotiate higher payments from insurance companies, which then pass on the higher costs to patients.” (K)

“The University of Pittsburgh Medical Center plans to invest $2 billion to build three “specialty hospitals” that include top-of-the-line technologies, the health system announced.
The $2 billion is in addition to $1 billion already set aside by UPMC for capital improvements, the organization said.
The three new facilities will be built near existing UPMC hospitals in Pittsburgh: UPMC Vision and Rehabilitation Hospital at UPMC Mercy; UPMC Hillman Cancer Hospital at UPMC Shadyside Hospital; UPMC Heart and Transplant Hospital at UPMC Presbyterian. (L)

San Diego-based Scripps Health is planning a $2.6 billion expansion — the largest construction project in the organization’s 125-year history.
The expansion will include constructing a $1.3 billion replacement hospital for Scripps Mercy Hospital San Diego; a new seven-story patient tower for San Diego-based Scripps Memorial Hospital La Jolla; and a three-story acute care structure at Scripps Memorial Hospital Encinitas (Calif.). In addition, seismic retrofitting construction is planned for Scripps Mercy Chula Vista (Calif.) and Scripps Green Hospital in San Diego. (M)

“Ohio State University intends to build a new hospital tower, which the university calls “the largest single facilities project ever undertaken at Ohio State.”
The university announced requests for qualifications Wednesday, seeking design professionals for two Wexner Medical Center projects anticipated to cost more than $2 billion: the tower and a new ambulatory center.
The envisioned hospital tower will have up to 840 beds in private rooms to elevate patient-centered care, safety and training for future physicians, the university said…
“This is an important moment in time,” said Wexner Medical Center board member Robert H. Schottenstein in a statement. “We are positioned to take a bold step forward by aligning all the operations of the medical center for the delivery of care, research and innovation that will have life-changing, long-term benefits for central Ohio, the State and beyond…. (N)

“Virtua Health can proceed with its plans to build a $1 billion hospital complex in Westampton, Burlington County, as long as it meets 13 conditions, the New Jersey Health Planning Board decided Thursday after reviewing the proposal…
The new hospital, which would have 339 beds and private rooms for all patients, would replace the Virtua Memorial Hospital in Mount Holly, three miles away…
The 399-bed Voorhees hospital, which opened in 2011, also was part of a $1 billion medical complex. A third Virtua hospital is in Marlton. (O)

“Moody’s Investors Service has issued a negative outlook on the nonprofit healthcare and hospital sector. The outlook reflects Moody’s expectation that operating cash flow in this sector will decline by 2 to 4 percent over the next 12 to 18 months.
The outlook revision comes amid uncertainty regarding federal healthcare policy for nonprofit hospitals and after the sector experienced a larger-than-expected drop in cash flow this year….
This marks the first time in several years Moody’s has issued a negative outlook on the nonprofit healthcare and hospital sector. The debt rating agency has maintained a stable outlook on the sector since August 2015. “(P)

Fitch Ratings’ outlook on the nonprofit healthcare sector is negative for 2018, as the sector faces regulatory, political and competitive challenges.
“..Fitch expects nonprofit hospitals and health systems’ profitability to continue to weaken over the next year. “Growth in Medicare and Medicaid volumes are weakening provider payer mixes at a time when providers are moving from volume-based reimbursement in greater numbers,” said Fitch Senior Director Kevin Holloran.” (Q)

“Dr. Peter Pronovost, one of the nation’s top patient safety experts and advocates, is leaving Johns Hopkins Health System for a job at insurance giant UnitedHealthcare, he announced Thursday on Twitter.
In a statement welcoming Pronovost to UnitedHealthcare, the insurer said he “has distinguished himself nationally and internationally with his ground-breaking work around saving lives, improving patient safety, and improving both the quality and value of health care…
“Dr. Pronovost’s patient-centered approach to care and deep clinical expertise will help bring a provider point-of-view deeper into UnitedHealthcare and improve how payers and care providers work together to share best practices, build appropriate value-based incentives, and effectively use data to improve the patient experience.”” (R)

“Rapid changes in the larger health care field are leading hospitals and health systems to explore new ways to enhance quality, reduce costs, and provide more convenient access to care to meet patients’ needs on their terms…hospital mergers can lead to substantial savings and provide needed funds to finance innovations that will enhance quality and convenience.
Benefits apply whether the hospitals involved are nearby, across the state or even across the country. A larger system allows hospitals to share infrastructure costs for expensive IT and reduce overlapping overhead costs.
It also expands the types of services available to patients and communities, and provides a stable foundation on which to deliver more comprehensive, coordinated and convenient care.”
America’s hospitals and health systems continue to build a high-performing, patient-centered system that benefits us all.
In some communities, mergers might be the only practical way to preserve services and enhance quality. In every case, the changes in the hospital field are in the service of providing a strong foundation upon which to build the health care system of the future and to continue to provide communities with the care they need in the consumer-friendly ways they expect.” (S)

“In theory, insurance companies hold down costs by driving hard bargains with providers. In reality, they find it difficult to do so.
UnitedHealth Group is the largest private health insurer, with about 11% of the overall market. Everyone else is less than 10% (though in local and regional markets there is more concentration).
That makes these insurers plenty big enough to beat up on consumers, but too small to take on powerful providers.
The result: In the USA, 18 cents of every dollar spent goes to health care each year. In other developed countries, health care expenditures are much less, in the range of 10 to 12 cents per dollar.
Which makes recent trends in the hospital industry all the more troubling. Two major hospital chains, Ascension and Providence St. Joseph Health, are in talks to merge, a move that would create a 191-hospital colossus operating in 27 states…
These massive businesses run much as their for-profit brethren — and will put pressure on for-profits to merge as well. That won’t be good for consumers, or the ridiculously high premium the American economy pays for a health care system that lacks effective cost controls.
Not all mergers in health care are problematic. The proposed combination of CVS, the owner of drug stores and walk-in clinics, with Aetna, a major insurer, holds intriguing possibilities for efficiencies and more comprehensive tracking of health care decisions.
It could also be argued that there should be more consolidation among insurance companies. This might not be a hugely popular concept, but it would give them more leverage to say no to costly increases demanded by hospitals and other potent health care providers.
At the very least, it’s time to take a critical eye to the mega hospital empires being erected. They could be very hazardous to your health.” (T)

“The CVS-Aetna deal did not come as a surprise to industry leaders who have been keeping their ears to the ground and have paid attention to recent trends. But nevertheless, this merger is a major shake-up that cannot be ignored. Google, Amazon and IBM Watson are all looking to stake out a piece of the healthcare field, and deals such as Optum’s purchase of DaVita Medical Group underscore the ever-evolving nature of the ways people access and pay for care and services. Providers should not view this movement as a threat that must be stopped. Instead, we should spur innovation on our end. We can’t sit still. That’s why, in Northwell Health’s case, we have been forging new partnerships and pursuing ventures that will enable the organization to compete more effectively in this rapidly changing environment.
It will be especially intriguing to see what market segments CVS and Aetna pursue after the merger is finalized. Undoubtedly, they will offer prescriptions, preventive care and other primary services to supplement CVS’ “Minute Clinics,” but it remains to be seen what other health services will be provided as part of this new collaboration. Regardless of what new competitors enter the healthcare market, the seriously ill, elderly patients with chronic conditions and those who have suffered traumatic injuries will still be relying on hospitals to take care of them. It’s highly unlikely that any of the new players will be providing inpatient care. As we all know, the bulk of healthcare funding is spent on long-term care for people at the end of life. The Amazons and Googles of the world are not targeting that population.” (U)

“It’s all about the patient.
Or at least about keeping patients and the revenue generated for their medical care.
As health care is rocked by deals aimed at shattering traditional boundaries between businesses, some of the nation’s biggest hospital groups are doubling down on mergers that seem much more conventional. Skeptics say some of these hospital deals are more of the same: systems seeking to increase their leverage with insurance companies and charge more for care…
But the frenzy of mergers and other alliances taking place also reveals a frantic attempt to court and capture patients as people have more choices about where to go for care. Patients are increasingly relying on walk-in clinics, urgent care centers or an app on their cellphone to check out a nasty rash or monitor their diabetes, and they are looking for places that are both less expensive and more convenient than a hospital emergency room or doctor’s office…
The fundamental question is whether hospital groups have what it takes to use their increased scale to radically change,…
But the challenge cannot be underestimated in asking these massive institutions to come together and change into something radically different. “You’re taking a zebra and a zebra,” Mr. Cassels said. “What they want to become is a unicorn.” (V)

“The $69 billion merger between CVS and Aetna is a powerful example of the “attacker’s advantage,” according to Ram Charan in an op-ed for strategy + business.
Mr. Charan is a business adviser and teacher who has spent 40 years consulting CEOs and executive boards. He defines the attacker’s advantage as “the competitive edge generated by leaders who can detect subtle shifts in consumer behavior, markets, and economic and social systems; who can spot an opportunity before others do; and who can lead their enterprises decisively to execute on that opportunity.” (W)

“….. no one should underestimate the challenge of growing the UnitedHealth acquisition of dispersed physician groups into a national system capable of disrupting our floundering health system. Health care is a very local affair, and the organizations providing it tend to be creatures of their localities and histories. It can take generations for a provider-insurer partnership to develop a culture of trust, collaboration, and value orientation that has made existing examples of these combinations so uniquely effective. If the new entity seeks to grow, it will find that recruiting and training physicians who can leave the fee-for-service mentality behind is a challenge, as is finding leadership that can gain and keep health professionals’ trust. Kaiser has failed in several attempts to spread to new locations. And though UnitedHealth’s Optum division, which will run the partnership, has some limited experience managing selected specialty health services, making this new enterprise work could prove daunting.” (A)

“Many Mayo Clinic doctors, nurses and other employees will be free to roll up their sleeves and show their ink in 2018 with a new policy allowing tattoos to be visible.
Mayo Clinic is loosening up its “Dress and Decorum Policy.” Currently, employees with tattoos are supposed to keep them covered at work or face discipline.” (X)

“New Hyde Park, N.Y.-based Northwell Health named Michelin Star chef Bruno Tison assistant vice president for food services and the corporate executive chef.
In his new role, Mr. Tison will oversee food quality, culinary training, menu and recipe development for the entire health system. His responsibilities will include teaching the health system’s cooks to make healthier and tastier food.” (Y)

(A) Is M&A the Cure for a Failing Health Care System?, David Blumenthal, https://hbr.org/2017/12/is-ma-the-cure-for-a-failing-health-care-system
(B) CVS to Buy Aetna for $69 Billion in a Deal That May Reshape the Health Industry, By MICHAEL J. de la MERCED and REED ABELSON, https://www.nytimes.com/2017/12/03/business/dealbook/cvs-is-said-to-agree-to-buy-aetna-reshaping-health-care-industry.html
(C) Why the CVS-Aetna deal could push Walmart to buy Humana, by Ayla Ellison, https://www.beckershospitalreview.com/payer-issues/why-the-cvs-aetna-deal-could-push-walmart-to-buy-humana.html
(D) UnitedHealth Buys Large Doctors Group as Lines Blur in Health Care, by REED ABELSON, https://www.nytimes.com/2017/12/06/health/unitedhealth-doctors-insurance.html?_r=0
(E) UnitedHealth’s Deal May Point to Health Care’s Future, by ROBERT CYRAN, https://www.nytimes.com/2017/12/06/business/dealbook/unitedhealth-davita.html
(F) Humana, private-equity firms buy Kindred Healthcare for $4 billion, by Ty Wright, https://www.cnbc.com/2017/12/19/humana-private-equity-firms-buy-kindred-healthcare-for-4-billion.html
(G) Dignity Health and Catholic Health Initiatives to Combine to Form New Catholic Health System Focused on Creating Healthier Communities, https://www.dignityhealth.org/about-us/press-center/press-releases/dignity-health-and-catholic-health-initiatives-announcement
(H) Hospital Giants in Talks to Merge to Create Nation’s Largest Operator, by Melanie Evans and Anna Wilde Mathews, https://www.wsj.com/articles/hospital-giants-in-talks-to-merge-to-create-nations-largest-operator-1512921420
(I) Catholic Hospital Mega-Deals Pressure For-Profits Like Tenet And HCA, Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/12/12/catholic-hospital-mega-deals-pressure-for-profits-like-tenet-and-hca/#41a1d7844c08
(J) CHS to sell additional hospitals worth $2B in revenue, by Ayla Ellison, https://www.beckershospitalreview.com/hospital-transactions-and-valuation/chs-to-sell-additional-hospitals-worth-2b-in-revenue.html
(K) CEOs describe health care partnership as a ‘marriage’, by Ames Alexander, Deon Roberts and Ann Doss Helms, http://www.charlotteobserver.com/news/business/article170440017.html
(L) UPMC will invest $2B to build 3 specialty hospitals, by Paige Minemyer, https://www.fiercehealthcare.com/finance/upmc-capital-investment-allegheny-health-network-hospital-expansion
(M) Scripps Health to launch $2.6B expansion, by Alia Paavola, https://www.beckershospitalreview.com/facilities-management/scripps-health-to-launch-2-6b-expansion.html
(N) New hospital tower would be Ohio State’s largest single project, by Jennifer Smola, http://www.dispatch.com/news/20171129/new-hospital-tower-would-be-ohio-states-largest-single-project
(O) Virtua wins health planning board OK to build a $1 billion medical campus in Westampton, by Jan Hefler, http://www.philly.com/philly/news/new_jersey/Virtua-Health-Westampton-hospital-Mount-Holly-medical-project.html
(P) Moody’s: Outlook is negative for nonprofit hospital sector, by Ayla Ellison, https://www.beckershospitalreview.com/finance/moody-s-outlook-is-negative-for-nonprofit-hospital-sector.html
(Q) Fitch issues negative outlook for nonprofit hospitals: 4 things to know, by Ayla Ellison, https://www.beckershospitalreview.com/finance/fitch-issues-negative-outlook-for-nonprofit-hospitals-4-things-to-know.html
(R) Top patient safety expert, innovator of checklists, departs Johns Hopkins, by Meredith Cohn, http://www.baltimoresun.com/health/bs-hs-peter-pronovost-leaves-hopkins-20171214-story.html
(S) Health care mergers benefit patients, by Rick Pollack, https://www.usatoday.com/story/opinion/2017/12/17/health-care-mergers-benefit-patients-editorials-debates/108704794/
(T) When hospitals merge, you pay the bill, https://www.usatoday.com/story/opinion/2017/12/17/when-hospitals-merge-you-pay-editorials-debates/953998001/
(U) Michael Dowling: 4 most important healthcare trends in 2018, by Written by Michael J. Dowling, https://www.beckershospitalreview.com/hospital-management-administration/michael-dowling-4-most-important-healthcare-trends-in-2018.html
(V) Hospital Giants Vie for Patients in Effort to Fend Off New Rivals, by REED ABELSON, https://www.nytimes.com/2017/12/18/health/hospitals-mergers-patients.html?_r=0
(W) Why the Aetna–CVS Deal Is a Lesson for Leaders, by Leo Vartorella, https://www.strategy-business.com/blog/Why-the-Aetna-CVS-Deal-Is-a-Lesson-for-Leaders
(X) Mayo to allow visible body art, with some exceptions, by Jeff Kiger, http://www.postbulletin.com/news/local/mayo-to-allow-visible-body-art-with-some-exceptions/article_4b0c7713-633b-5230-86d7-5468901bcf3c.html
(Y) Northwell first health system in nation to hire Michelin Star chef, by Anuja Vaidya, https://www.beckershospitalreview.com/hospital-executive-moves/northwell-health-appoints-assistant-vp-of-food-services-corporate-executive-chef-3-takeaways.html

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