‘This Is Like in War’ – Lessons Learned about Hospital Hurricane Preparedness

“Failing infrastructure, the increasing density of cities and the growing frequency of extreme weather events create public health risks on a massive scale. In Houston, improperly maintained Superfund sites ― that is, profoundly polluted hazardous-waste sites ― could not withstand the waters that rose as high as streetlights in some areas. Drainage systems failed. Poisonous chemicals and dangerous bacteria spread via floodwater through residential areas. In the wake of a flood, mold can bloom inside devastated structures, putting people at risk of allergies, asthma and other respiratory problems.
As with Houston, overdevelopment in Florida is making people more vulnerable to hurricanes and flooding, as precious swampland and marshland is encased in concrete and high-density residential zones are built in risky areas like barrier islands. Hurricane Irma, which made landfall in Florida on Sept. 10, knocked out power for between 60 and 80 percent of residents across the state, underlining the need for more diverse kinds of energy infrastructure.” (A)

“All hospital systems maintain emergency plans of action for a looming crisis such as Irma…
Hospitals have electrical generators in place if needed, are tied into their local government’s emergency operations response centers, and have preselected and specially trained administrators and medical staff at the ready, along with their relief teams. Non-critical surgeries and routine patient checkups are postponed, and clinics and physician practices closed…
Systems with multiple locations have specific plans for each “based on hazards,” such as proximity to the ocean or river, said Karen Ketchie, Baptist Health’s director of emergency management services. That’s how they were prepared to move patients when conditions at each site warranted it, she said…
“The hospital … was built to enable a defend-in-place strategy. This is due to the high acuity of our population of patients, and removing them from the building might be dangerous,” he said. (B)

“After an estimated 215 people died in hospitals and nursing homes in Louisiana following Hurricane Katrina in 2005, policy makers realized that the nation’s health care institutions were ill-prepared for disasters.
One of the rules they created after years of discussion looked especially prescient in light of the tragic deaths on Wednesday of eight nursing home residents in Florida’s post-hurricane heat. But the rule, regarding power supplies and temperature control, will not be enforced until November, and even then, some patient advocates are concerned that it does not go far enough…
The new federal rule will require that nursing homes have “alternate sources of energy to maintain temperatures to protect resident health and safety.” But the rule does not specifically require backup generators for air-conditioning systems — the nursing home in Florida, Rehabilitation Center at Hollywood Hills, did not have such a generator — and now some are questioning whether the rule should.” (C)

Escalating a legal and regulatory fight, Gov. Rick Scott’s administration issued an emergency suspension of the license of a Broward County nursing home Wednesday after the deaths of nine residents following Hurricane Irma.
The license suspension was another step after the state Agency for Health Care Administration last week placed a moratorium on admissions to The Rehabilitation Center at Hollywood Hills and suspended the facility from the Medicaid program. The nursing home late Tuesday filed a lawsuit challenging the admissions moratorium and the Medicaid cutoff.
Eight of the residents died Sept. 13, three days after Hurricane Irma shut down the nursing home’s air-conditioning system. The license suspension alleged that four of the residents had body temperatures of at least 107 degrees when they arrived at a nearby hospital or when they died.
“Respondent (the nursing home) failed to maintain safe conditions in its facility; failed to timely evacuate its facility once conditions were no longer safe for residents; and failed to timely contact ‘911’ during a medical emergency,” said the emergency suspension order, signed by AHCA Secretary Justin Senior. (D)

First, the nursing home, called the Rehabilitation Center at Hollywood Hills.
Yes, it experienced a partial loss of power after Irma. But the real problem appeared to be that the staff didn’t act quickly enough after the air conditioning failed and patients became overheated and dehydrated, according to police, emergency responders, and family members of patients.
By the time emergency responders got there, the facility’s second floor was “extremely hot,” some patients were already dead, and others were near death, Hollywood Police Chief Tom Sanchez told reporters.
Also, help was just a few steps away. Memorial Regional Hospital, which is right across the street, had power and a fully functioning emergency room when the deaths occurred.
When the hospital finally learned what was happening, dozens of workers rushed over to help, says Randy Katz, an Emergency Medicine specialist at Memorial. (E)

The first call from the Rehabilitation Center of Hollywood Hills to Florida Power & Light was placed about six hours after Hurricane Irma made landfall in Cudjoe Key on Sunday.
Irma had knocked out power to the center where 141 elderly and frail patients lived, and the following morning FPL said it would be there to restore electricity to the air conditioning units, according to a time line provided to the Miami Herald on Friday by officials of the nursing home who asked not to be identified.
The allegations in the time line — that the facility called both FPL and the governor’s cellphone for help that didn’t come, along with comments from the state and the governor’s office denying the nursing home’s version of events — added confusion Friday to a case that includes a criminal investigation into the deaths by Hollywood police.
According to the nursing home time line, FPL didn’t show up as promised on Monday, or on Tuesday, and by the time the utility arrived on Wednesday morning to repair a transformer that powered the nursing home’s air conditioners, all of the patients had been evacuated and eight elderly residents were dead. (F)

“The Texas Hospital Association this week estimated that as many as 75,000 hospital employees experienced losses and damage from Hurricane Harvey, both the storm and subsequent flooding. The association, which is based in Austin and represents more than 85 percent of the state’s acute-care hospitals and health care systems that combined employ some 365,000 health care professionals, announced Sept. 5 that it is contributing $1 million to a special assistance fund for the affected employees….
“Throughout the storm and the days following, we witnessed firsthand the dedication of our health care workforce,” said Ted Shaw, THA’s president and CEO. “Many of these individuals stayed committed to their work, knowing their families and property were at risk. While hospital administrative personnel, nurses, and other staff train for unspeakable disasters like Hurricane Harvey, their preparation and focus ensured the safety and continued operation of facilities even as the waters rose and the lights went out. Now, it’s time for us to take care of the caregivers.” (G)

“Patricia Ney was a nurse. The 56-year-old worked in the obstetrics department at Cape Coral Hospital for more than three years. In total, her career spanned more than three decades. Until last week…
The hospital system’s emergency preparedness plan in case of hurricanes is called “Code Brown.” During hurricanes, essential employees are grouped into two groups — A and B. Group A staffs the hospital during the storm and Group B takes over after to relieve the first staff workers.
Ney was part of Group A, but the day after Labor Day she went to Pennsylvania on a previously planned trip. At the time, Irma was forecasted to hit the east coast of Florida, but the cyclone surprised all by going west instead.
Under the previous guidelines for Code Brown situations, employees who did not go to work were placed under corrective actions and in some circumstances fired.
But because Irma was so remarkably unpredictable and affected large swaths of the state, Briggs said the guidelines will be tweaked allowing those employees to return to work. (H)

Local emergency management officials and state public health officials dodged a bullet with Hurricane Irma. They must do a better job of coordinating with local hospitals the care of hurricane evacuees who have been deemed “medically needy” because of serious health issues.
Emails obtained by this newspaper showed that as Hurricane Irma bore down on Chatham County, the three local hospitals initially flinched and backpedaled on their previous agreements to house 48 fragile members of the community, and that only Memorial University Medical Center eventually lived up to its commitments, but only after Chatham Emergency Management Agency Director Dennis Jones did some serious arm-twisting with top Memorial execs.
Candler accepted none of the evacuees it was assigned and St. Joseph’s, Candler’s sister hospital in the two-hospital system, accepted three “last minute” cases. (I)

“Furniture damaged by floodwater during Hurricane Irma that’s now sitting in front of people’s homes has started attracting people looking to salvage metal from it. But there is a hidden danger that could lead to infection if you aren’t careful.
On Jacksonville’s Northside, which saw a lot of flooding, two men were seen salvaging materials from soaked furniture…
“E.coli is the most common bacteria that can cause a variety of different problems,” Ashbaugh said. “Also, people with staph and strep — that can become a big problem with cellulitis, different abscesses and skin diseases.” (J)

“Nancy Reed, 77, died on Sept. 15 of flood-related necrotizing fasciitis, an infection that spreads quickly through muscle tissue and can cause organ failure…
According to the Centers for Disease Control and Prevention, necrotizing fasciitis is a serious bacterial skin infection that kills the body’s soft tissue, spreads quickly and can be fatal in a short time. Prompt diagnosis and treatment with antibiotics can prevent death.
The infection is not considered a reportable disease in Texas, meaning doctors or laboratories who diagnose it are not required to alert health authorities. But they are required to report many of the organisms that cause the disease — streptococcus, E. coli, vibrio vulnificus and certain types of drug-resistant staphylococcus.
Strep is the most common cause of flesh-eating bacteria. Vibrio is the most common in salt water. (K)

“The major general hospital for the Caribbean island of Dominica has already taken a major beating from Maria. It’s too early to tell just how much damage there will be to the Puerto Rican health system; but medical facilities on the island have historically been underfunded, putting even more strain on health care providers in the midst of an economic crisis in the region. And widespread power outages are expected for the foreseeable future, which will force patients to rely on backup generators and aid organizations.” (L)

“Health and safety are always concerns after such a disaster, but Puerto Rico must try to address those with the island largely devoid of electrical power and with a severely damaged communication system…
There are immediate needs of making sure hospitals can continue to run on generators, which require fuel that is in demand. It’s unknown how many people are trapped in homes that can’t get to a hospital or need some kind of health aid, such as a nebulizer, medication or assistance with getting around…
Jaime Pla, president of the Puerto Rico Hospital Association, told NBC News that hospitals have been able to operate normally for the past 48 hours because they have been on generator power.
“The issue we’re going to have is accessibility to diesel,” said Pla, adding that most generators operate on diesel tanks that last between three to five days…
All of this comes after Puerto Rico’s medical system already was strained as doctors have been leaving the island because of the economic crisis, as NBC News reported last month.” (M)

“The hospitals have been crippled by floods, damage and shortages of diesel. The governor said that 20 of the island’s hospitals are in working order. The rest are not operational, and health officials are now trying to determine whether it is because they lack generators, fuel or have suffered structural damage. All five of the hospitals in Arecibo, Puerto Rico’s largest city in terms of size, not population, are closed.
Making matters worse, 911 still does not work, officials said…
So far, seven regional hub hospitals are taking in patients. The island’s dialysis patients are also getting care. But none of it is easy. Hospitals should be required to have backup generators, diesel, a stockpile of medication and satellite phones, the doctor added. Even with those precautions, problems could arise. There is enough diesel on the island, but a shortage of gas tanker drivers — some cannot get to their jobs — and working gas stations. In Lares, the mayor, Roberto Pagan, said the municipal hospital almost had to close yesterday because it ran out of diesel fuel.
“We have been putting out fires,” Dr. Rodríguez-Mercado said. “The hospitals call you and say, ‘I have two hours of diesel left.’” (N)
.
“Coast Guard planes are flying in fuel, food and water from Miami and Jacksonville. The Navy hospital ship, U.S.N.S. Comfort, with 1,000 beds and 12 operating rooms, is also headed to the island. And the Department of Defense announced that U.S. Northern Command will have a commander on the ground in 24 hours.
“The issue in responding on an island is that you can’t drive trucks in like you can on mainland U.S.,” said Will Booher, a spokesman for FEMA…
At Centro Medico in San Juan, the main hospital on the island, power went out again Tuesday, forcing staff to switch to generators that have to be constantly refueled, said Jorge Matta González, the hospital’s executive director of medical services. (O)

“Aid is finally reaching the islands—fuel for generators, water, medical supplies, food—but disasters always breed disasters. And that might be what’s about to happen in Puerto Rico, too. “The first impact is people who were directly injured,” says Nahid Bhadelia, medical director of the special pathogens unit of the National Emerging Infectious Disease Laboratories at Boston University. “Then you have an entire group of people who are critically ill, facing health care systems that are overwhelmed.”
If things don’t get fixed quickly, the third wave comes. The islands are dealing with standing water, little clean water, and high heat. Those are perfect conditions for waterborne and mosquito-borne diseases—diarrheal diseases, and things like chikungunya, Zika, and dengue.” (P)

‘About 90 patients evacuated from Puerto Rico and the Virgin Islands are receiving kidney dialysis at Florida International University in Southwest Miami-Dade under a hurricane recovery response program coordinated by the state’s Department of Health.
Among the most urgent patients evacuated from Puerto Rico were the three infants with heart defects, who were born in August and September…
For transportation, Nicklaus Children’s turned to its LifeFlight program, an air ambulance service that flies jets packed with advanced life-support equipment for transferring critically ill newborns from the Caribbean, and Central and South America to Miami for medical care.” (Q)

“Evacuees from Puerto Rico and the U.S. Virgin Islands are being transported to mainland hospitals to receive care for critical medical conditions caused or impacted by Hurricane Maria.
In South Carolina, more than a dozen evacuees have arrived at the Columbia Metropolitan Airport by C-130 or private jet to be transported to various medical facilities around the state’s capitol…
In Puerto Rico, 59 out of 68 hospitals are open but not considered fully functional. Troy and her team from Fort Jackson are a part of the National Disaster Medical System, N.D.M.S, and Federal Coordination Center, F.C.C, which were activated in cities within the southern states of Louisiana, Mississippi, Georgia, and South Carolina in an effort to provide free medical assistance to those suffering from life threatening issues.” (R)

“Texas hospitals canceled surgeries, evacuated patients, and closed for days because of Hurricane Harvey. They sank millions of dollars into not caring for patients as a measure of precaution.
More than a month after Harvey made landfall, administrators at the roughly two dozen hospitals that evacuated in the eastern part of the state have now reopened their doors to patients. But some may feel the financial burdens of the storm for months to come — both caring for more patients who can’t afford treatment, while also seeing patients postpone the more lucrative elective surgeries that are many hospitals’ moneymakers.” (S)

“Hurricane Maria took almost everything from Rodriguez save for what he could fit into a backpack: the medical school he attended on the Caribbean island nation of Dominica and his family’s home in Puerto Rico. But he vows it won’t take his future — indeed, it has helped him find it.From his uncle’s house in Homestead, Florida, Rodriguez calls his experience surviving Maria “life-decisive.” In an interview by phone, he told CNN it has pushed him to pursue a new career path in his final semester at Ross University School of Medicine — emergency medicine.It was a decision born in the midst of a crisis.” (T)

“With Hurricane Irma menacing Florida, the leader of a state university campus decided on her course of action: Flee. As the storm approached earlier this month, Sophia Wisniewska dashed off an email to her boss. It included a description of the campus and indicated all was quiet at the University of South Florida at St. Petersburg.
It did not include any indication that Wisniewska was decamping for Atlanta…
Now, Wisniewska is out of her job as regional chancellor at USFSP, forced to negotiate her resignation. USF officials this week released a copy of the resignation agreement to The Washington Post, as well as a draft of a scathing termination letter from USF System President Judy Genshaft. (U)

(A) How Houston Can Become Stronger After Hurricane Harvey, by Anna Almendrala, http://www.huffingtonpost.com/entry/houston-hurricane-city-infrastructure_us_59c019f0e4b093cfe7761771
(B) Hurricane Irma: How Jacksonville-area hospitals responded to latest weather crisis, by Beth Reese Cravey, http://jacksonville.com/news/metro/2017-09-15/hurricane-irma-how-jacksonville-area-hospitals-responded-latest-weather-crisis
(C) Nursing Home Deaths in Florida Heighten Scrutiny of Disaster Planning, by NEIL REISNER and SHERI, https://www.nytimes.com/2017/09/14/us/nursing-home-deaths-irma.html?_r=0
(D) State suspends license of nursing home where 9 died after Hurricane Irma, by Jim Saunders, http://www.orlandosentinel.com/news/breaking-news/os-hurricane-irma-nursing-home-suspended-20170920-story.html
(E) When Irma Arrived, Most Florida Health Care Facilities Were Ready, by JON HAMILTON, http://www.npr.org/sections/health-shots/2017/09/19/551920301/when-irma-arrived-most-florida-health-care-facilities-were-ready
(F) Nursing home says calls for help went unanswered but state disputes claims, by DANIEL CHANG, http://www.miamiherald.com/news/weather/hurricane/article173630881.html
(G) Harvey Affected About 75,000 Hospital Employees in Texas, https://ohsonline.com/articles/2017/09/22/harvey-hospital-employees.aspx?admgarea=news
(H) Lee Health fires then rehires its essential employees who did not work during Irma, by MELISSA MONTOYA, http://www.news-press.com/story/news/local/2017/09/21/lee-health-fires-then-rehires-its-essential-employees-who-did-not-work-during-irma/687117001/
(I) Editorial: Come up with better plan for medically needy evacuees, http://savannahnow.com/opinion/editorial/2017-09-23/editorial-come-better-plan-medically-needy-evacuees
(J) Storm debris, floodwater-soaked furniture pose health risks, doctors warn, by Erik Avanier, https://www.news4jax.com/weather/hurricane-irma/storm-debris-floodwater-soaked-furniture-pose-health-risks-doctors-warn
(K) Kingwood woman confirmed as Harvey death from flesh-eating bacteria, by Cindy George and Todd Ackerman, http://www.chron.com/houston/article/Kingwood-woman-confirmed-as-Harvey-death-from-12230105.php
(L) Hurricane Maria Could Devastate Puerto Rico’s Underfunded Health System, by Sy Mukherjee, http://fortune.com/2017/09/20/hurricane-maria-puerto-rico-hospitals/
(M) Puerto Rico Attempts Recovery Amid Escalating Crisis and Dam Failure, by SUZANNE GAMBOA, https://www.nbcnews.com/news/latino/puerto-rico-precarious-situation-hurricane-recovery-begins-n803926
(N) The Crisis at Puerto Rico’s Hospitals, by OLGA KHAZAN, https://www.theatlantic.com/health/archive/2017/09/the-crisis-at-puerto-ricos-hospitals/541131/
(O) ‘This Is Like in War’: A Scramble to Care for Puerto Rico’s Sick and Injured, by LUIS FERRÉ-SADURNÍ, FRANCES ROBLES and LIZETTE ALVAREZ, https://www.nytimes.com/2017/09/26/us/puerto-rico-hurricane-healthcare-hospitals.html?mcubz=0
(P) https://www.nytimes.com/2017/09/28/opinion/puerto-rico-hurricane-maria.html?mcubz=0, by AM ROGERS, https://www.wired.com/story/puerto-rico-health/
(Q) Stranded in Puerto Rico after Hurricane Maria, infants flown to Miami for heart surgery, BY DANIEL CHANG, http://www.miamiherald.com/news/health-care/article176662251.html
(R) Hurricane Maria victims airlifted to mainland hospitals from US Virgin Islands and Puerto Rico, by Terace Garnier, http://www.foxnews.com/health/2017/10/04/hurricane-maria-victims-airlifted-to-mainland-hospitals-from-us-virgin-islands-and-puerto-rico.html
(S) Texas hospitals feeling the long-term financial strains of Harvey, byy MAX BLAU, https://www.statnews.com/2017/10/03/harvey-hurricane-texas-hospitals/
(T) Hurricane Maria took everything, but it gave med student a calling, by Paul P. Murphy, http://www.cnn.com/2017/10/06/us/hurricane-maria-survivors-story-future-trnd/index.html
(U) This university leader fled Florida during Hurricane Irma. Now she’s been ousted, by Sarah Larimer, https://www.washingtonpost.com/news/grade-point/wp/2017/09/20/this-university-leader-fled-florida-during-hurricane-irma-now-she-has-been-ousted/?utm_term=.88fe8b891f6d

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As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save.

“The Las Vegas University Medical Center looked like a war zone when trauma surgeon Jay Coates arrived just after 11 p.m. PT to care for the scores of wounded victims of the largest mass shooting in U.S. history.
“We started divvying them up, taking them to the operating room and doing what’s called ‘damage control surgery,’ where you’re not definitively repairing everything,” Coates, a medical profession of two decades, recalled. “You are just stopping the dying.”
That’s exactly what medical staff did. John Fildes, trauma center medical director, said UMC received more than 45 trauma patients Sunday night. Although some died before they reached the hospital, “the patients who arrived alive have all survived,” Fildes said.”
As he looked at the full beds and patients “packed and stacked in the hallways,” he shifted into triage mode, asking himself “Who’s dying first?” and who could he save….” (A)

University Medical Center is the only level-one trauma center in Nevada and one of only a few free-standing trauma units in the nation. That means it is fully staffed with surgeons and trauma nurses day and night to handle injuries and mass casualties, from vehicle crashes that bring in 10 patients at a time to a 2015 episode in which a woman drove onto the Las Vegas Strip, sending 17 patients to the medical center. Last week, there had been 15 trauma cases in one night.
But even with 11 trauma bays, three operating rooms, a CT scanner, a trauma intensive care unit and a pediatric intensive care unit all under one roof, the trauma center had never faced a torrent like this. For two or three hours, the patients came nonstop. The radio at the clerk’s desk blared with transmissions from paramedics. With the frequency overburdened, other paramedics resorted to calling in patients by phone. Many patients simply arrived in cars or, in one instance, several in the back of a truck.
To an outsider, “it would look like a disaster zone, a chaotic scene, very chaotic,” Ms. Mullan said. “If a nonmedical person were to be sitting there watching this, they would think nothing was being accomplished.”
But in fact much was being done. It had been a busy day, which meant some of the day shift was still present and stayed to work alongside the night shift. Pagers went off with a be-beep be-beep each time a severe trauma case was identified. Patients, most of them with gunshot wounds, were doubled up two stretchers to a trauma bay. At one point, beepers screeched as five trauma cases were clocked in at the same time. “We couldn’t hear each other talk, it was that crazy,” Ms. Mullan said…
“The patients who arrived alive have all survived,” Fildes said. (B)

to read about my experiences with mass casualty events, We don’t know what we don’t know”…The challenge to emergency preparedness…..highlight and click on http://doctordidyouwashyourhands.com/2017/08/we-dont-know-what-we-dont-know-1-the-challenge-to-emergency-preparedness/

Dr. Jay Coates, a trauma surgeon at UNLV School of Medicine, said it was a night of non-stop surgeries.
“It was a little bit of controlled chaos. We’ve had mass casualties come through this trauma center but nothing of this magnitude,” he told Las Vegas station KTTV.
To save as many lives as possible during a tragic event like this, first responders and emergency room doctors must act quickly and make difficult decisions.
“It’s an ethical and moral dilemma that all physicians and health care providers go through because we try to save everyone, but unfortunately that’s not the case,” Dr. Robert Glatter, an emergency room doctor at Lenox Hill Hospital in New York, told CBS “This Morning.”
On the scene, he explains, there is a tagging system that prioritizes wounded patients based on who needs to be seen first.
People who have life-threatening injuries and need immediate attention, such as those with a collapsed lung, are tagged red and are brought in for treatment right away.
Those with severe, but less life-threatening injuries are ranked a tier lower with a yellow tag.
Unfortunately, doctors must also decide when a patient cannot be saved.
“Say there’s a person with a head injury who’s barely breathing. We try to open their airways but if there’s not much chance of saving them we have to move on,” Glatter said. (C)

“…. 100 extra doctors were called in to work Sunday night, along with another 100 people including nurses, technicians, and support staff.
“We have a relatively large emergency department. We were able to triage within our emergency department,” he says. “We used the hallway space to see patients, so it’s a lot fuller than it normally would be and it feels a lot more chaotic.”
At University Medical Center, patients were being triaged in the ambulance bays, Cohen told CNN. The hospital has an 11-bay trauma center, with three operating bays, as well as regular surgery suites, which they likely used in this situation.
“We can get patients from an ambulance into the OR [operating room] in one minute,” Cohen says.
As reports of the gunfire emerged shortly after 10:30 p.m. PST Sunday, the city’s trauma centers began calling in extra personnel.
People working in trauma centers train for such emergencies and would know they’re likely to have to report to work as soon as they heard about the shooting on the news or social media. But still, the scale of this incident may have been surprising. “When you think of more than one hundred shooting victims, ballistic injuries, that is an absolute giant number,” says Bruno Petinaux, the chief medical officer and co-chair of emergency management at the George Washington University Hospital in Washington, D.C.
“When you’re talking about a mass casualty incident like this, this is where you call in the backup, and you call in the backup to the backup, and you may have to message the rest of your medical staff that you may need their help,” he says. (D)

The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation.
Most major cities have such a plan, says Ian Weston, executive director of the American Trauma Society, which advocates for victims of trauma and the trauma care system.
“Hospitals are prepared to build capacity,” he says. “They’ll get the most critical patients into surgery quickly, they’ll stabilize more in the ER and some will even be treated in the lobby.”
He says hospitals determine exactly how many people they can care for in such a situation, even taking into account how many people they can fit into hallways, at least temporarily.
Hospitals across the Las Vegas area were inundated Sunday evening when hundreds of people injured in the mass shooting at a country music festival on the Strip arrived at their doors by ambulances and private car.
And hundreds of doctors, nurses, and support personnel were called into work to help handle the patients that were lined up in ambulance bays and hallways, officials say…
The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation. (E)

“All hospitals in North Carolina have a common agreement for mutual aid. We also have, through our disaster planning, some teams which are available that can be shared between areas,” she said.
Bisset said WakeMed regularly plans emergency response training and drills to practice for a major disaster of any kind, including infectious disease outbreaks, like Ebola, or a chemical attack. However, mass shootings with military-style weapons pose a special set of problems for critical care responders.
“We have the good fortune that a number of our trauma surgeons have served in the military and so they are very well trained with war wounds, because this is what we’re really talking about when you have many of these weapons,” she said.
Bisset said that, on any given day, WakeMed could already be at capacity. In such an event, plans are in place for moving non-critical care patients to other facilities. (F)

In moments like these, doctors, nurses, and technicians lean on their training for most of the required actions. But in every calamitous circumstance—and this is a calamitous medical emergency—there are intricacies that could never have been predicted. And that’s where improvisation comes in. Things that would never be done under normal circumstances can end up saving lives—police cars broke protocol after the 2013 Boston Marathon bombing and put bleeding victims into the back seats of their units and drove them to the hospital themselves, rather than waiting for ambulances. This move, which had also occurred after the Aurora, Colorado, shooting, likely lowered the death toll.
After each catastrophe, leaders such as my colleague Eric Goralnick, medical director for emergency preparedness at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School and the T.H. Chan School of Public Health, share experiences, both domestically and internationally. Paris learns something from Boston: Tourniquets, long out of fashion, had turned out to be helpful in the field. In turn, Boston had learned something from Aurora: Mass casualty drills in Boston had never accounted for such a large number of victims until officials realized in the wake of Aurora that they needed to prepare for circumstances that had previously seemed too remote to train for.
Emergency departments like the ones that treated victims from Las Vegas are forced to develop their protocols based more on anecdote than evidence.
Man-made mass casualty incidents seem increasingly common. But are medical teams actually learning enough from them? Are we really getting any better? (G)

(A) LAS VEGAS STRIP SHOOTING, AT LEAST 50 DEAD, by Brett Kellman, https://www.usatoday.com/story/news/nation-now/2017/10/02/las-vegas-shooting-hospital-you-just-stopping-dying/725466001/
(B) Controlled Chaos at Las Vegas Hospital Trauma Center After Attack, by SHERI FINK, www.nytimes.com/2017/10/02/us/vegas-shooting-hospital.html?_r=0
(C) ‘It’s not a matter of if, it’s when’ How Las Vegas hospitals prepared for a massacre, by Dan Mangan, https://www.cnbc.com/amp/2017/10/02/las-vegas-hospitals-dealing-with-hundreds-of-mass-shooting-victims.html
(D) Las Vegas Hospitals Call For Backup To Handle Hundreds Of Shooting Victims, by Alison Kodjak, http://www.npr.org/sections/health-shots/2017/10/02/555044797/las-vegas-hospitals-call-for-back-up-to-handle-hundreds-of-shooting-victims
(E) Las Vegas Shooting Update: At Least 59 People Are Dead After Gunman Attacks Concert, by Bill Chappell and Doreen McCallister, http://www.npr.org/sections/thetwo-way/2017/10/02/554976369/section-of-las-vegas-strip-is-closed-after-music-festival-shooting
(F) Response to Las Vegas shooting offers lesson to local trauma centers, by Allen Mask, http://www.wral.com/response-to-las-vegas-shooting-offers-lesson-to-local-trauma-centers/16989905/
(G) Hospitals Aren’t Fully Prepared for Mass Shootings, and It’s the Gun Lobby’s Fault, Jeremy Samuel Faust, http://www.slate.com/authors.jeremy_samuel_faust.html

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Access to health care….should be considered “privileges” for those who can afford them

“When asked by a high school student in Wisconsin whether he considered health care a right or a privilege, Sen. Ron Johnson (R-WI) compared access to health care to access to food and shelter, arguing that all three should be considered “privileges” for those who can afford them.
“I think it’s probably more of a privilege,” Johnson said in response to the question. “Do you consider food a right? Do you consider clothing a right? Do you consider shelter a right? What we have as rights are life, liberty, and the pursuit of happiness. We have the right to freedom. Past that point, everything else is a limited resource that we have to use our opportunities given to us so that we can afford those things.”
Johnson then went on to argue that the role of elected officials is not to guarantee everyone a right to health care, but to grow the economy so that more people can afford access to health care. (A)

“The ACA is safe for now. … Americans cannot afford to disarm in the fight for accessible healthcare…
The faults of the ACA have been scrutinized since its inception. Rising insurance premiums have left individuals searching for cheaper plans with limited options for coverage. But none of the Republicans’ solutions address these problems.
Instead, new problems would arise if either of the GOP-proposed bills had passed—including the loss of Medicaid for many low-income people. The Graham-Cassidy bill was thrown together so hastily that a score from the Congressional Budget Office was not available, although the office did release a statement saying that millions would lose healthcare coverage.
In addition, the government would no longer require insurers to cover a comprehensive list of benefits like prescription medicine, emergency care, drug rehab and a host of other medically necessary treatments.” (B)

“…The cruelty of the U.S. Senate’s Graham-Cassidy health care bill exceeded its failed predecessors. The question isn’t so much why the bill died, it’s why such an abomination was even born. And could it happen again?
Graham-Cassidy would have done much more than simply repeal and replace the Affordable Care Act. It would have changed federal Medicaid participation from a system that matches state funding to one imposing arbitrary caps – decimating the “traditional Medicaid” predating the ACA by 45 years…
Eventually, however, every state would have lost. For all the talk of “returning power to states,” states must balance their budgets. Medicaid is frequently on the chopping block, even in relatively good times. State policymakers of both parties must reject any illusion that Medicaid “block grants” and other ideological games would make their jobs easier…
Graham-Cassidy would have shred an already-tenuous, half-century-old social safety net. It would have led to care rationing, and hastened deaths, for our most vulnerable. The threat may recur, and members of Congress must be told to resist such immorality.” (C)

“…Two senators of different parties have resumed negotiations that offer a more productive path, one that could preserve the best of Obamacare while offering adjustments that both parties can accept.
The talks between Lamar Alexander, a Republican from Tennessee, and Patty Murray, a Democrat from Washington, might not succeed, of course. Republican leaders scuttled a previous attempt by the two senators because they wanted another shot at repeal, an effort that failed ignominiously last week. Mr. Alexander and Ms. Murray hope to offer Congress a way out of the morass with a modest bill that could help strengthen the A.C.A.’s individual insurance markets, which are used by about 10 million people, without overhauling the whole system in ways that could deprive millions of people of subsidized care…
The senators’ compromise would also offer states more freedom than the A.C.A. now allows to attract insurers; some rural states are down to just one insurer in their marketplaces, and premiums have jumped. Democrats have resisted such changes before, fearing that any waiver from federal rules would be exploited by states to reduce mandated services like those for maternity care, cancer and pre-existing conditions. Ms. Murray is said to be insisting, as she must, that any new flexibility for states does not become a back door for watering down protections.” (D)

“Trump has picked Don Wright, who has been director of the Office of Disease Prevention and Health Promotion, as acting secretary in the interim. But Trump has several options for replacing Price. Trump might go with a governor, since they’re used to running large health-care programs. Or he might promote someone within HHS — most likely Seema Verma — or someone elsewhere in his administration. A few senators’ names have surfaced as possible picks, too.
Here’s a list of the top names being circulated: CMS Administrator Seema Verma; FDA Commissioner Scott Gottlieb; Rick Scott, governor of Florida; Veterans Affairs Secretary David Shulkin; Former Louisiana governor Bobby Jindal; Charlie Baker, governor of Massachusetts; Rick Santorum, former senator from Pennsylvania.” (E)

(A) Republican senator calls health care, food, and shelter a ‘privilege’, by NATASHA GEILING, https://thinkprogress.org/ron-johnson-health-care-a-privilege-1d9fe371b55a/
(B) Health-care debate far from over after latest GOP bill fails, http://www.columbiachronicle.com/opinion/article_a663677c-a565-11e7-ba89-57fa3613c3ae.html
(C) Commentary: As bad as Graham-Cassidy was, could it return?, by Brendan Williams, https://www.heraldnet.com/opinion/commentary-as-bad-as-graham-cassidy-was-could-it-return/
(D) Actually, a Health Care Deal Is Possible, https://www.nytimes.com/2017/10/02/opinion/obamacare-bipartisan-healthcare-deal-.html?_r=0
(E) The Health 202: Trump could pick one of these people to replace Price at HHS, by Paige Winfield, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/10/02/the-health-202-trump-could-pick-one-of-these-people-to-replace-price-at-hhs/59cee63d30fb0468cea81cb4/?utm_term=.72fadf8afb74

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Senator Cassidy a candidate for Health and Human Services Secretary?

“Sen. Cassidy failed to repeal ObamaCare, but the defeat hasn’t stopped Louisiana’s senior senator from trying to raise money from the effort.
A fundraising pitch sent this week from Cassidy’s campaign urged supporters to send donations by a Saturday deadline to “help Bill keep fighting for what we all know is right.”
The email describes Cassidy as working “to keep every Republican’s promise in repealing and replacing the disastrous Obamacare” and said he’s become a “target of liberals across the country” because of it.
The fundraising request doesn’t mention that Cassidy’s legislation, co-sponsored by South Carolina Sen. Lindsey Graham, didn’t have enough GOP support for passage and was shelved this week as the Senate moves on to a debate about taxes.” (A)

“Bipartisan health insurance proposal expected next week. “What we’re trying to do is not just see whether Sen. Murray and I can agree, but whether the two of us can find a significant number of Democrats and Republicans who can agree on a limited, bipartisan proposal that could actually pass,” said Alexander, chairman of the Senate Health, Education, Labor and Pensions Committee.
Murray, the committee’s top Democrat, also is optimistic about the discussions. “After all the partisanship we’ve seen from Republicans on health care, I’m glad we’ve been able to restart our conversations about ways to actually make health care work better for families — beginning with steps to help lower premiums — and I’m hopeful we can reach a final agreement soon,” she said.
While negotiations are still ongoing, Alexander and Murray are looking to give states more flexibility in the type of policies that they can approve and to extend for two years the federal cost-sharing payments that enable insurance companies to reduce premiums for lower- and middle-class Americans. President Trump has threatened to stop the payments, which are worth about $7 billion this year. “ (B)

“Republicans who control Congress moved one step closer Friday to overhauling the tax code — one of their top legislative goals — in an effort that also puts a repeal of the Affordable Care Act on the back burner for at least the near future….
Republicans want to pass tax reform using budget reconciliation, a procedural tool that would allow them to advance their bill with a simple 51-vote majority, rather than the typical 60. Since Republicans have a 52 to 48 majority in the Senate, the lower voting threshold would make it possible for them to pass tax reform without help from Democrats.
Senate Republicans used budget reconciliation — which can only be used once per fiscal year — in their attempt to repeal and replace Obamacare this year. But despite many attempts, they failed to pass a health care bill in their allotted time to do so under reconciliation, which expires Saturday.” (C)

“Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., the two authors of the latest Republicans effort to overhaul Obamacare to collapse in the Senate, met with President Trump on Thursday and afterwards said they look forward to continue the debate over healthcare, even as Congress turns its focus to tax reform….
“Over the coming weeks and months, we are committed to holding congressional hearings and working with our nations’ governors who believe returning power to states is a vast improvement over Obamacare,” the duo said in a statement after meeting Trump, who was a major proponent of their efforts….
…. the senators said they have the backing of the president who “remains committed to repealing and replacing Obamacare” and furthermore “the principles brought forward in Graham-Cassidy-Heller-Johnson.” “ (D)

“President Trump’s selection of a secretary of health and human services could be a turning point in a health care debate that has polarized Washington, as he faces a choice of working with Democrats to fix the current system or continuing his so-far failed efforts to dismantle his predecessor’s program…
The White House had no comment Saturday, but the two most frequently mentioned candidates to succeed Price are two officials who work in the department: Seema Verma, administrator of the Centers for Medicare and Medicaid Services, and Scott Gottlieb, commissioner of the Food and Drug Administration…
If Trump picks Verma to succeed Price at the Department of Health and Human Services, it would be taken as a sign among many that he wants to continue vigorous opposition to the Affordable Care Act, with the government doing the minimum required by the law to implement its provisions.” (E)

“Another potential candidate is Florida’s Republican Gov. Rick Scott, a former hospital executive who is term-limited after 2018. But Scott is expected to mount a Senate campaign against Democratic incumbent Sen. Bill Nelson next year, and he may have ambitions and interests beyond health care…
Also mentioned is Louisiana GOP Sen. Bill Cassidy, co-author of the last Republican health care bill that failed to advance. Cassidy would probably win confirmation easily, but his prospects in the Senate appear bright, and he may not want to depart for a Cabinet post in a tumultuous administration.” (F)

(A) U.S. Sen. Bill Cassidy asks for campaign donations after health care legislation fails, http://www.wdsu.com/article/us-sen-bill-cassidy-asks-for-campaign-donations-after-health-care-legislation-fails/12655941
(B) Sen. Lamar Alexander: Bipartisan health insurance proposal expected next week, by Michael Collins, http://www.tennessean.com/story/news/politics/2017/09/29/sen-lamar-alexander-bipartisan-health-insurance-proposal-expected-next-week/717579001/?from=global&sessionKey=&autologin=
(C) Budget panel officially sidelines Obamacare repeal, makes path for GOP tax plan, by Ashley Killough and Ted Barrett, http://www.cnn.com/2017/09/29/politics/tax-reform-budget-repeal-obamacare/index.html
(D) Graham-Cassidy authors ‘committed’ to hearings on healthcare after meeting with Trump, by Daniel Chaitin, http://www.washingtonexaminer.com/graham-cassidy-authors-committed-to-hearings-on-healthcare-after-meeting-with-trump/article/2636025
(E) Choice of new health secretary may offer clue to Trump’s next move on health law, by Peter Baker, https://www.bostonglobe.com/news/nation/2017/09/30/choice-new-health-secretary-may-offer-clue-trump-next-move-health-law/22SKFwfSaqtv8CuYcfMgJL/story.html
(F) Price’s Exit Further Complicates GOP Health Care Push, by JILL COLVIN and RICARDO ALONSO-ZALDIVAR, https://www.usnews.com/news/business/articles/2017-09-30/prices-exit-further-complicates-gop-health-care-push

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“Senate Republicans Commence Health Care Blame Game” – pointing fingers at each other. (But..Is a bipartisan deal next?)

“Frustration overtook Senate Republicans on Tuesday as the reality sunk in that they had failed again in fulfilling a seven-year campaign promise to repeal the 2010 health care law. And senators were looking to cast blame wherever they could find it.
They decried the time constraints of the budget reconciliation procedure they chose to advance a bill with only Republican support.
They chastised Democrats for their lack of assistance, despite making no serious effort to work across the aisle during the past nine months.
They blamed the top-down approach to negotiating the legislation that leadership employed.
Some criticized the carve-outs to states whose senators were skeptical of the proposal, a strategy that resulted in near daily updates to the already complex legislation….” (A)

“Two U.S. senators from both parties are close to finalizing a bipartisan deal to shore up the health insurance exchanges created under Obamacare, the chamber’s top Democrat said on Thursday…
Schumer said Senate Health, Education, Labor and Pension Committee Chairman Lamar Alexander, a Republican, and ranking Democrat Patty Murray had resurrected a bipartisan approach, which had been cast aside amid the latest near-vote on a repeal bill.
Alexander and Murray had been working to protect the government payments made to insurers to help reduce medical expenses for low-income Americans enrolled in Obamacare. Alexander also wanted states to have more flexibility to design insurance plans under the program…
The pact could buoy health insurance companies, which came out forcefully against the Republican repeal effort and have faced uncertainty since the November election of Republican President Donald Trump, who vowed to sink the law.” (B)

“It’s far from clear that any deal Murray and Alexander work out could win approval from the full Senate, let alone pass the House.
Many other Senate Republicans, including Senate Finance Committee Chairman Orrin Hatch (R-Utah), are more skeptical of a deal to stabilize ObamaCare than Alexander is.
And the House and White House are another question entirely.
Speaker Paul Ryan (R-Wis.) has told the Senate that an Alexander-Murray deal “isn’t viable” for the House GOP.
As Republicans sought to win support for their repeal effort, some spoke dismissively of the Alexander-Murray talks, suggesting anything the senators agreed upon would go nowhere in the House…
An expansion of waivers currently in ObamaCare that allow states to innovate and change regulations are also said to be part of the potential deal, though it is not clear how far those waiver changes will go.
Those provisions are both Republican requests.
The main provision for Democrats would be funding for key ObamaCare payments known as cost-sharing reductions, which President Trump has threatened to cancel in a bid to make the health-care law “implode.”” (C)

(A) Senate Republicans Commence Health Care Blame Game, by Joe Williams, http://www.msn.com/en-us/news/politics/senate-republicans-commence-health-care-blame-game/ar-AAsv5qg?li=BBmkt5R
(B) Senators close to bipartisan deal on health exchanges: Schumer, https://www.reuters.com/article/us-usa-healthcare/senators-close-to-bipartisan-deal-on-health-exchanges-schumer-idUSKCN1C32UL
(C) Senators zero in on deal to stabilize ObamaCare markets, by PETER SULLIVAN, http://thehill.com/policy/healthcare/352957-senators-zero-in-on-deal-to-stabilize-obamacare-markets

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LINDSEY GRAHAM ON OBAMACARE REPEAL: I HAD NO IDEA WHAT I WAS DOING

“.. now that it’s over, the old Graham is back and more than willing to laugh at how improbable it was that a national security expert briefly held the national limelight as a supposed health policy wonk.
Graham, though, said he was not alone in his lack of understanding of health care. “Nobody in our conference believes Obamacare works. It must be replaced. But until now, we didn’t know how to do it,” Graham told reporters in the Capitol on Tuesday, audio of which is posted below.
A reporter pointed out that such ignorance at this late stage is hard to understand. “You’ve been working to overhaul this for seven years. Why is this so hard?” she asked. “Well, I’ve been doing it for about a month. I thought everybody else knew what the hell they were talking about, but apparently not,” Graham clarified, adding he had assumed “these really smart people will figure it out.” (A)

“Stung by another health care defeat this week, President Trump said Wednesday he will begin talking with Democrats on legislation that can replace the law signed by predecessor Barack Obama.
“I will negotiate with Democrats to see if we can make a bipartisan bill,” Trump told reporters at the White House, the day after Senate Republicans’ last-ditch proposal to unwind the Affordable Care Act collapsed on Capitol Hill. The president said he hopes for a health care vote in January, February or March.
In the meantime, the president said he plans to sign an executive order – likely next week – that would enable people to buy health insurance across state lines, though there is some question as to whether a president has the authority to effect such a change.” (B)

“Sen. Rand Paul, R-Ky., predicted Wednesday that President Trump would soon move on his own to make health insurance more affordable, after the Senate failed again this week to advance any bill to reform federal healthcare policy.
“I believe that President Trump can legalize on his own the ability of individuals to join a group or a health association across state lines and buy insurance,” he added.
Paul he has been pitching the idea of using the Employee Retirement Income Security Act to let people buy insurance across state lines. That law already allows corporations to buy insurance across state lines for their workers if they are located in several states.” (C)

“Sen. John Cornyn (R-Texas) is floating potentially tying a bipartisan deal on stabilizing the health insurance market to structural reforms favored by Republicans, after the latest bill to repeal and replace ObamaCare fell apart.
“Sen. [Lamar] Alexander [R-Tenn.] and Sen. [Patty] Murray [D-Wash] are working on some ideas on stabilizing the market, but more importantly, to me, Sen. [Bill] Cassidy [R-La.] and Sen. [Lindsey] Graham [R-S.C.] are looking at structural reform,” the No. 2 Senate Republican told reporters Tuesday.
Cornyn hasn’t previously appeared optimistic that he would be able to support a potential deal hatched by Alexander and Murray — the top two members on the Senate Health Committee — aimed at stabilizing the insurance market and providing ObamaCare’s cost-sharing reduction payments to insurance companies.
He added on Tuesday that he still wasn’t optimistic of the potential agreement as a stand-alone bill, saying, “I remain unconvinced that bailing out insurance companies is going to fix the problem.”
“That’s why if somehow we can combine the efforts of Cassidy and Graham for real reform, that might provide a potential solution,” he said.” (D)

“Graham and his co-conspirators previously said they would demand that tax cuts and health care reform be lumped together if they failed to make headway on health care in September. But on Tuesday, Graham changed course, saying he is now willing to let tax reform go ahead on its own because he had been unaware how complex tying the two together would be. Then, in the spring, Graham said, he will insist on a new budget resolution that allows for another crack at repeal using a 50-vote threshold — what is called budget reconciliation in the Senate.
Before Republicans spend another year plotting an ACA repeal, they may want to reflect on whether they have what it takes to get those 50 votes…..” (E)

“Trump said there would be another vote on healthcare in the first few months of 2018 and he would work with Democrats to make the effort more bipartisan. Democrats strongly oppose repealing and replacing Obama’s signature domestic policy achievement.
“I am … going to meet with Democrats and I will see if I can get a healthcare plan that’s even better,” Trump said. “So I will negotiate with Democrats, but from the Republican standpoint, we have the votes. We’ll vote in January, February or March.”
Trump did not explain the discrepancy between his conviction that the votes were there and the fact that not enough Republican senators supported the latest bill, forcing Republican leaders to scrap plans to hold a vote.” (F)

(A) LINDSEY GRAHAM ON OBAMACARE REPEAL: I HAD NO IDEA WHAT I WAS DOING, Ryan Grim, Aída Chávez, https://theintercept.com/2017/09/27/lindsey-graham-on-obamacare-repeal-i-had-no-idea-what-i-was-doing/
(B) Trump says he’ll negotiate with Democrats on health care plan, by David Jackson, https://www.usatoday.com/story/news/politics/2017/09/27/trump-says-hell-negotiate-democrats-health-care-plan/708790001/
(C) Rand Paul: Trump will take executive action on healthcare after Senate failure, by Pete Kasperowicz, http://www.washingtonexaminer.com/rand-paul-trump-will-take-executive-action-on-healthcare-after-senate-failure/article/2635769
(D) Key GOP senator floats tying bipartisan insurance stabilization deal to reforms, by JORDAIN CARNEY, http://thehill.com/policy/healthcare/352585-key-gop-senator-floats-tying-bipartisan-insurance-stabilization-deal-to
(E) THE GOP’S UNPREDICTABLE PATH TO HEALTH CARE REPEAL IN 2018, by Ryan Grim, Aída Chávez, https://theintercept.com/2017/09/28/republican-health-care-repeal-2018-graham-cassidy/
(F) Trump vows another healthcare vote next year, eyes executive order, by Jeff Mason, Susan Cornwell, http://www.reuters.com/article/us-usa-healthcare/trump-vows-another-healthcare-vote-next-year-eyes-executive-order-idUSKCN1C21IA

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Last minute Sunday night Graham Cassidy revisions included.. a pretty sweet deal for the state of Louisiana, home of one of the bill’s sponsors Sen. Bill Cassidy.

“Republican senators released a new version of their health care proposal Sunday night aimed at winning support from a handful of still undecided senators. The legislation includes language that gives states that expanded Medicaid after December 2015, access to an additional $750 million a year between 2023 and 2026.
Experts at both the Kaiser Family Foundation and the Brookings Institution confirmed CNN’s understanding that the provision would only make two states eligible for the millions in funding: Montana and Louisiana. That money, however, wouldn’t just be divided evenly — Louisiana would get tens of millions more because it’s population is larger, according to one expert.” (A)

“For now, people who get their insurance through Medicaid can rest easy…. Those with employer insurance can also coast along with the status quo….Most Obamacare customers won’t feel the sting of higher premiums, because government subsidies limit their exposure to a percentage of their income. But there are still millions of people who buy their own insurance and earn too much to qualify for subsidies. The rocky market will be worse for them, and possibly unaffordable.
Senators in the Health, Education, Labor and Pensions committee had been negotiating over a possible bipartisan deal to help stabilize the markets. The expected package would have guaranteed the disputed payments to insurers and provided states with some policy flexibility in future years.
But that effort was shelved by congressional leadership as part of the failed push to pass the Graham-Cassidy health care overhaul. Now, with contract signings imminent, it is probably too late for lawmakers to improve conditions much for next year.” (B)

“Already, state insurance regulators are approving big rate increases based on the assumption that Trump will discontinue CSR payments and Congress will not appropriate them….
It’s not just the CSR’s raising rates. Industry analysts say companies are also pricing in doubts about whether the White House will enforce the Obamacare individual mandate, which requires people to maintain coverage.” (C)

“The push to repeal Obamacare took on new life after a party lunch meeting two weeks ago at the Senate GOP’s campaign headquarters. There, they were presented with a dour assessment of the party’s finances as donors rebelled against a party that had abandoned its promise.
“Failure of health care has made the problem we had worse. It’s not just [contested] primaries but donors. Let me tell you, online giving went down 40 percent after we failed on health care. Pledges to the Republican Party went down 60 percent. And I understand that,” said Graham, who cheekily called such feedback “employer assessments.”” (D)

“ “We haven’t given up on changing the American health care system,” Senator Mitch McConnell of Kentucky, the majority leader, said after a lunchtime meeting of Republican senators. “We are not going to be able to do that this week, but it still lies ahead of us, and we haven’t given up on that.”
Democrats, who have spent all year fighting to protect the Affordable Care Act, a law that is a pillar of President Barack Obama’s legacy, responded by calling for the resumption of bipartisan negotiations to stabilize health insurance markets. Republican leaders had squelched those talks as the latest repeal plan, written by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, gained steam…
Senator Lamar Alexander, Republican of Tennessee and the chairman of the Senate health committee, and Senator Patty Murray of Washington, the senior Democrat on the panel, have been working on legislation to stabilize insurance markets and hold down premiums in the next couple of years. Both said on Tuesday that they hoped to resume those efforts.” (E)

“President Donald Trump tweeted his assurance Wednesday that Republicans will have enough votes to repeal Obamacare, one day after the GOP canceled its vote on the Graham-Cassidy healthcare bill…
“We will have the votes for Healthcare but not for the reconciliation deadline of Friday, after which we need 60,” Trump said. “Get rid of Filibuster Rule!” (F)

(A) Newest Graham-Cassidy bill has a pretty sweet deal — for Cassidy, by Lauren Fox, http://www.cnn.com/2017/09/25/politics/graham-cassidy-deal-for-sponsor/index.html
(B) How Failure of the Obamacare Repeal Affects Consumers, by Margot Sanger-Katz, https://www.nytimes.com/2017/09/26/upshot/how-the-failure-of-obamacare-repeal-affects-consumers.html?mcubz=0
(C) Obamacare Repeal Failed, but the Damage Is Already Done, by BENJY SARLIN, https://www.nbcnews.com/politics/congress/obamacare-repeal-failed-some-damage-already-done-n804956
(D) Inside the life and death of Graham-Cassidy, by JENNIFER HABERKORN, BURGESS EVERETT and SEUNG MIN KIM, http://www.politico.com/story/2017/09/27/obamacare-repeal-graham-cassidy-243178
(E) Senate Republicans Say They Will Not Vote on Health Bill, by THOMAS KAPLAN and ROBERT PEAR, https://www.nytimes.com/2017/09/26/us/politics/mcconnell-obamacare-repeal-graham-cassidy-trump.html?mcubz=0
(F) Trump tweets ‘we have the HCare Vote, but not for Friday!’ after the Graham-Cassidy healthcare bill collapses by Jonathan Ernst, http://www.businessinsider.com/trump-tweets-on-healthcare-bill-graham-cassidy-failure-filibuster-2017-9

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