DOCTOR tracked ZIKA last year and proposed the designation of REGIONAL EMERGING VIRUSES REFERRAL CENTERS.
It seems that when it was an isolated mainland event in south Florida, public concern disappeared and public health authorities breathed a sigh of relief.
Even though we now know that more ZIKA outbreaks are likely and that the consequences for some babies will be catastrophic, authorities apparently are leaving every hospital to plan on its own.
Here’s one reason centralized planning is a necessity and Referral Centers need to be designated.
The New York Times story, by Catherine Saint Louis, noted:(A)
“Women who do not have any symptoms of Zika virus still may give birth to a baby with Zika-related birth defects, research has shown. The only way to catch those infections is to screen women because they may have been exposed to Zika-infected mosquitoes or may have had sexual contact with an infected partner.
In this new report, “The presence or absence of symptoms was not predictive of whether a baby would be damaged,” … “There were women who had asymptomatic Zika whose babies were damaged.”
Currently, only about 60 percent of babies born alive in United States territories had results of Zika laboratory testing reported to pregnancy and infant registries. It’s important that all babies who may have been affected are monitored, as early intervention can help.
For instance, some babies who appear normal at birth later develop an unusually shrunken head. Only with long-term tracking can health officials get an accurate estimate of the scope of the problem.”
Previous ZIKA related DOCTOR posts:
ZIKA UPDATE #1. EBOLA is back in Africa. Is ZIKA next? Are we prepared? (B)
All pregnant women with Zika diagnosed at community hospitals must be referred to academic medical centers for prenatal care! (C)
Former hospital prez says: Designate local Zika centers now. “Medical experts do not know if, or where, or how much, or on what trajectory the Zika virus may spread across the United States.” (D)
With the guidance of an experienced and thoughtful physician I just made a decision to end a course of diagnostic testing after slowly getting to that decision point.
But I have family members and friends who have gone through a full “best practices” diagnostic regimen only to wind up in an ambiguous situation, then having treatment that may or may not have been necessary, too often without getting a second opinion.
So, as usual, I started Googling:
Dr. Atul Gawande a prominent Harvard Medical School Professor of Surgery and New Yorker writer reflected on eight patients he saw in his practice one day, after reviewing their medical histories.
“To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (B)
Dr. H. Gilbert Welch, a professor at Dartmouth Medical School, and a nationally recognized expert on the effects of medical testing, wrote “….. the conventional wisdom is that more diagnosis—particularly, more early diagnosis—means better medical care. The logic goes something like this: more diagnosis means more treatment, and more treatment means better health. This may be true for some. But there is another side to the story. More diagnosis may make healthy people feel more vulnerable—and, ironically, less healthy. In other words, excessive diagnosis can literally make you feel sick. And more diagnosis leads to excessive treatment—treatment for problems that either aren’t that bothersome or aren’t bothersome at all. Excessive treatment, of course, can really hurt you. Excessive diagnosis may lead to treatment that is worse than the disease.” (C)
In another article Dr. Welch wrote this case study (very abbreviated here, link to full text is in the footnotes)
“Mr. Nadeau was eighty-five and in excellent health. He went to see his doctor simply for a routine checkup. The doctor performed a careful physical exam. Everything looked good, except for a bulge he thought he felt in Mr. Nadeau’s belly—a bulge that might be an abdominal aortic aneurysm. ….
The ultrasound showed that Mr. Nadeau’s aorta was normal…But the ultrasound found something else to worry about. It found something abnormal on Mr. Nadeau’s pancreas….A CT scan showed the pancreas was normal.
But the CT scan found something else to worry about. It found a nodule on Mr. Nadeau’s liver. The radiologist recommended a liver biopsy to see what the nodule was (it could be cancer too). ….The pathologic diagnosis was hemangioma, a benign growth made up of lots of blood vessels.
Given that a small knitting needle was cutting through a growth full of blood vessels, you won’t be surprised by what happened next. Bleeding. Mr. Nadeau was in the hospital for a week……
That’s too much medicine. (D)
Here are some ways you can play a role in assuring appropriate levels of diagnostic testing:
1. Do some homework using CHOOSING WISELY. Choosing Wisely is an initiative of the ABIM Foundation in partnership with Consumer Reports that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. http://www.choosingwisely.org/
2. Five Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure. Do I really need this test or procedure? What are the risks and side effects? Are there simpler, safer options? What happens if I don’t do anything? How much does it cost, and will my insurance pay for it? (E)
3. Second opinions are fairly routine. They bring peace of mind and encourage patient engagement… “If your physician doesn’t support you getting a second opinion, see how fast you can run.”… “Any doctor who is any good at what they do will welcome a second opinion, because it will usually be a confirming opinion.” (F)
4. As you get referred to specialists make sure your PRIMARY CARE PHYSICIAN keeps fully informed, coordinates your care and helps you fully understand your options.
(A) Over-Testing, Over-Diagnosis & Emergency Medicine: Does it Exist and Does it Matter?, by Rick Bukata, https://medium.com/@emabstracts/over-testing-over-diagnosis-emergency-medicine-does-it-exist-and-does-it-matter-fabc10d9e252
(B) Overkill, An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? by Atul Gawande, The New Yorker, http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
(C) ‘Overdiagnosed’ by Gilbert Welch et al, NYT, http://www.nytimes.com/2011/01/25/health/25zuger_excerpt.html
(D) There Is Such a Thing As Too Much Medical Care, by H. Gilbert E. Welch, http://www.sciencefriday.com/person/h-gilbert-welch/
(F) A Patient’s Guide to Second Opinions, by Kristine Crane, http://health.usnews.com/health-news/patient-advice/articles/2014/07/23/a-patients-guide-to-second-opinions
Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.
Speaking at the release of President Trump’s first budget, Mick Mulvaney, the White House budget director, said: “We’re going to measure compassion and success by the number of people we help get off of those programs and get back in charge of their own lives. We’re not going to measure our success by how much money we spend, but by how many people we actually help.” (A)
Mulvaney’s underlying premise: “We need people to go to work. If you’re on food stamps, and you’re able-bodied, we need you to go to work. If you’re on disability insurance and you’re not supposed to be — if you’re not truly disabled, we need you to go back to work. We need everybody pulling in the same direction.” (B)
One of the big targets for reductions is Medicaid.
“We hear a lot about Medicaid in both the local and national media. It is oftentimes classified as a free program for those disinterested in working and paying their fair share, making it one of the most misunderstood and misperceived programs on the books.
It is imperative that everyone across the nation understand the purpose of Medicaid — that it is not for people who do not want to work or are simply looking for a handout. Medicaid is a safety net for everyone because we are all one medical crisis or catastrophic event away from financial ruin. It is a stepping stone for people when the unexpected occurs. It is for the middle class, for the financially stable, and even for those who once considered themselves upper class. If you have worked during your life, Medicaid is a program you helped fund and one that is available to you and your children when you need it the most. But few know exactly what that means.
To be clear, Medicaid covers more than just low-income families, it covers children, pregnant women, the elderly and the significantly disabled. AND, IT WILL COVER YOU IF EVER NECESSARY. (C)
In 2015, Medicaid provided health coverage for 97 million low-income Americans over the course of the year. In any given month, Medicaid served 33 million children, 27 million adults (MOSTLY IN LOW-INCOME WORKING FAMILIES), 6 million seniors, and 10 million persons with disabilities, according to Congressional Budget Office (CBO) estimates.
Children account for more than two-fifths of Medicaid enrollees but less than one-fifth of Medicaid spending. Only slightly more than one-fifth of Medicaid enrollees are seniors or persons with disabilities, but because they need more (and more costly) health care services, they account for nearly half of Medicaid spending. (D)
“When debating health care, we tend to talk far more about health insurance than about the institutions giving the actual care. Whatever the government decides to spend, poor people will get sick. And when they get sick enough, they will receive treatment. This is because federal law requires all hospitals to provide emergency care to all patients, regardless of their ability to pay.
For uninsured patients, lifesaving surgeries and treatments, along with a limited recovery period, are often covered through Emergency Medicaid funds. But patients who don’t fit neatly into our medical system for reasons of health or finances or their social situation — the “medical misfits” that any one of us can become under the wrong circumstances — need far more long-term support. This is often where safety-net hospitals step in. (E)
If Medicaid is cut that does not mean that those formerly covered do not get care. They go to the nearest Emergency Room usually at an academic medical center or teaching hospital, “safety-net” hospitals, the same place we all go when the highest level of care is required. But the hospital either does not get paid or gets underpaid putting its finances in jeopardy, and therefore its surge capacity, the ability to take on community emergencies like the flu or Zika, and compromises its disaster preparedness.
“Almost 470,000 additional New Jersey residents wouldn’t have health insurance coverage under the House Republican-passed bill to repeal and replace the Affordable Care Act, according to a report released Thursday.
More than half of the 469,500 residents — 246,000 — would not be covered due to the American Health Care Act’s $834 billion cut to Medicaid, which would end the extra federal funding for new enrollees in states like New Jersey that expanded the program under the current health care law.” …of which about 56,000 would be in Hudson County served by Jersey City Medical Center where I was President and CEO for 17 years. (F)
Cutting Medicaid has a ripple effect on safety-net hospital sustainability which eventually will impact on access to health care for all of us.
(A) Trump Budget Cuts Programs for Poor While Sparing Many Older People by Yamiche Alcindormay, NYT, https://www.nytimes.com/2017/05/22/us/politics/budget-food-stamps-poverty.html
(B) Off-camera Briefing of the FY18 Budget by Office of Management and Budget Director Mick Mulvaney, https://www.whitehouse.gov/the-press-office/2017/05/22/camera-briefing-fy18-budge-omb-director-mulvaney
(C) Medicaid: A Stepping Stone, Not a Stigma, by Mark A. Wallace, Hufffington Post, http://www.huffingtonpost.com/mark-a-wallace/medicaid_b_2396186.html
(D) Policy Basics: Introduction to Medicaid, http://www.cbpp.org/research/health/policy-basics-introduction-to-medicaid
(E) Where Will the Medical Misfits Go? Safety-net hospitals keep us all healthy by treating the patients no one else wants. Don’t let Republicans destroy them by Ricardo Nuilamay, NYT, https://www.nytimes.com/2017/05/26/opinion/sunday/safety-net-hospitals-health-care.html?_r=1
(F) NJ Politics Digest: 470,000 in NJ Could Lose Health Coverage by Steve Cronin The Observer, http://observer.com/2017/05/nj-politics-digest-470000-in-nj-could-lose-health-coverage/
…according to Iowa Republican Congressman Raúl R. Labrador. *
But New York Democratic Congressman Sean Patrick Maloney got it right when he said “Any member of congress who voted for the bill should be obligated to join a high risk pool.” **
HIGH RISK HEALTH INSURANCE POOLS in Trump/ Ryan Care carve out individuals with pre-existing conditions but does not guarantee them access to affordable health care.
This is under-the-radar but that’s why we need to be vigilant. So here’s a nerdy HIGH RISK 101.
The House Trump/ Ryan Care bill… would allow states to apply for waivers for certain ObamaCare provisions, such as a ban on insurers charging premiums based on a customer’s health and the requirement that insurers’ basic health plans cover certain services, like prescription drugs and mental health.
How do we know this was a dodge?
An under-the-radar GOP amendment would have exempted members of Congress and their staffs to ensure that they will still be protected by those ObamaCare provisions. It was deleted after it was discovered. (A) When Congress tries to exempt itself, we know its shenanigans!
High-risk pools are private, self-funded health insurance plans organized by state to serve high-risk individuals who meet enrollment criteria and do not have access to group insurance. (B)
“High-risk pools are a key concept that helped House Republicans pass their replacement for the Affordable Care Act. That bill, the American Health Care Act…allows states to opt out of the requirement for insurers to cover people with preexisting conditions and set up high-risk pools for these people instead. A late amendment to the bill added $8 billion* in additional funding over five years for these potential pools, and that change garnered enough new Republican votes for AHCA to pass the House.” (C)
“In a nutshell, high-risk pools: are prohibitively expensive to administer, are prohibitively expensive for consumers to purchase, and offer much less than optimal coverage, often with annual and lifetime limits, coverage gaps, and very high premiums and deductibles.” (D)
There have been state high-risk pools for 35 years, prior to the ACA. A recent Kaiser Health Foundation report on the state programs noted: “These high-risk pools likely covered just a fraction of the number of people with pre-existing conditions who lacked insurance, due in part to design features that limited enrollment. State pools typically excluded coverage of services associated with pre-existing conditions for a period of time and charged premiums substantially in excess of what a typical person would pay in the non-group market.” (E)
“…unless high risk pools are adequately subsidized, high premium costs will mean all high need consumers will not be able to afford coverage. State policymakers will need to address those implications as more consumers may face personal bankruptcies and unmet needs, and as states witness an increase in the number of uninsured and more demand for uncompensated care.” (F)
“The history of high-risk pools demonstrates that Americans with pre-existing conditions will be stuck in second-class health care coverage — if they are able to obtain coverage at all.” (G)
WHAT OTHER DAMAGE TO ACCESS IS BURIED IN THE BILL THAT HOUSE MEMBERS DIDN’T READ BEFORE THEY VOTED FOR IT?
** WAMC public radio
(A) House GOP health bill changes exempt members of Congress by Peter Sullivan, The Hill, http://thehill.com/policy/healthcare/330592-house-gop-health-bill-changes-exempt-members-of-congress
(B) CONSUMER GUIDE TO HIGH-RISK HEALTH INSURANCE POOLS, NAHU, http://www.nahu.org/consumer/hrpguide.cfm
(C) Sounds Like A Good Idea? High-Risk Pools, by Julie Rovner and Francis Ying, KHN, http://khn.org/news/sounds-like-a-good-idea-high-risk-pools/
(D) Why High Risk Pools (Still) Won’t Work, by Jean P. Hall, Commonwealth Fund, http://www.commonwealthfund.org/publications/blog/2015/feb/why-high-risk-pools-still-will-not-work
(E) High-Risk Pools For Uninsurable Individuals, by Karen Pollitz, http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/
(F) High Risk Pools Deja Vu – Lessons from States, Questions for Policymakers, by Trish Riley and Anita Cardwell, NASHP, http://www.nashp.org/high-risk-pools-deja-vu-lessons-from-states-questions-for-policymakers/
(G) High-risk pools won’t match Obamacare’s protections for pre-existing conditions by Tami Luhby, CNN, http://money.cnn.com/2017/05/03/news/economy/high-risk-pools-obamacare-pre-existing
“No Surprise Charges” is one of the key Lessons Learned in Elisabeth Rosenthal’s fabulous new book AN AMERICAN SICKNESS (Penguin Press, 2017). “Hospitals in your network should also be required to guarantee that all doctors who treat you are in your insurance network.”
We have all harshly experienced or heard about under-the counter out-of-network hospital charges:
(A) “A Kaiser Family Foundation survey finds that among insured, non-elderly adults struggling with medical bill problems, charges from out-of-network providers were a contributing factor about one-third of the time. Further, nearly 7 in 10 of individuals with unaffordable out-of-network medical bills did not know the health care provider was not in their plan’s network at the time they received care.”
(B) A new study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an “out-of-network” doctor — and thus exposed to additional charges not covered by their insurance plan.”
Here is a brief case study:
“When Janet Wolfe was admitted to the hospital near Macon, Georgia, a few years ago, her lungs were functioning at just one-fifth their normal capacity. The problem: graft-versus-host disease, a complication from a stem cell transplant she received to treat lymphoma. Over the course of three days she saw three different doctors. Unbeknownst to Janet and her husband, Andrew, however, none of them was in her health plan’s network of providers. That led the insurer to pay a smaller fraction of those doctors’ bills, leaving the couple with some hefty charges.” (C)
So what can you do to avoid out-of-network charges? (D)
– Speak with a practice representative before being seen to understand the costs of seeing your doctor on an out-of-network or a cash basis. (DOCTOR note: maybe you need to leave and go to an in-network physician instead)
– If you need additional services, such as surgery, imaging or physical therapy, ask your doctor to refer you to an in-network facility to keep your costs down.
A New York law is a great start toward transparency to reduce out-of-network surprises.
Under a recent New York law, Hold Harmless Protections for Insured Patients, “… patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.
A bill is considered a surprise if consumers receive services without their knowledge from an out-of-network doctor at an in-network hospital or ambulatory surgical center, among other things. In addition, if consumers are referred to out-of-network providers but don’t sign a written consent form saying they understand the services will be out of network and may result in higher out-of-pocket costs, it’s considered a surprise bill. (E)
(A) Surprise Medical Bills by Karen Pollitz, kkf.org, http://kff.org/private-insurance/issue-brief/surprise-medical-bills/
(B) Many get hit with surprise ‘out-of-network’ bill after emergency rooms: Study” by Dan Mangan, CNBC, http://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-out-of-network-bill-after-emergency-rooms-study.html
(C) When Out-Of-Network Charges Pop Up, Try An Appeal, by Michelle Andrews, NPR, http://www.npr.org/sections/health-shots/2011/06/21/137304710/when-out-of-network-charges-pop-up-try-an-appeal
(D) What It Means If Your Doctor is Out of Network, by Sergio Viroslav, Angie’s list, https://www.angieslist.com/articles/what-it-means-if-your-doctor-out-network.htm
(E) N.Y. Law Offers Model For Helping Consumers Avoid Surprise Out-Of-Network Charges by Michelle Andrews, KHN http://khn.org/news/n-y-law-offers-model-for-helping-consumers-avoid-surprise-out-of-network-charges/
Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).
1. There should not be an automatic default to just designating Ebola Centers as REVRCs although there is likely to be significant overlap.
2. REVRCs should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and emerging viruses “reading” expertise).
3. National leadership in clinical trials.
4. A track record of successful, large scale clinical Rapid Response.
5. Organizational wherewithal to address intensive resource absorption.
REVRC protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.
Fast forward to this weekend: “There have been 17 suspected cases and two confirmed cases of Ebola in Congo’s Bas-Uele province,…. Of the 19, three deaths have been reported. …. health officials were trying to located 125 people believed to be linked to the cases.” (A)
What are we waiting for? DESIGNATE REVRCs NOW!
(A) EBOLA RETURNS: WHAT YOU NEED TO KNOW ABOUT THE OUTBREAK IN CONGO, by BY CONOR GAFFEY, Newsweek, http://www.newsweek.com/democratic-republic-congo-ebola-609143
EMERGENCY ROOMS are not all created equal! http://doctordidyouwashyourhands.com/2016/04/emergency-rooms-are-not-all-created-equal/
We don’t know what we don’t know” http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/
Former hospital prez says: Designate local Zika centers now. http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/
“I got Zika. The US health care system had no idea what to do with me…” http://doctordidyouwashyourhands.com/2016/08/i-got-zika-the-us-health-care-system-had-no-idea-what-to-do-with-me/
“With little known about Zika virus, hospitals scramble to stay ahead.” http://doctordidyouwashyourhands.com/2016/08/with-little-known-about-zika-virus-hospitals-scramble-to-stay-ahead/
Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense? http://doctordidyouwashyourhands.com/2016/09/hospitals-are-developing-their-own-zika-preparedness-models-compare-the-central-florida-and-johns-hopkins-approaches-which-template-makes-more-sense/
“PRE-EXISTING CONDITIONS” is a predatory insurance industry term, not a medical term.
“Think it can’t get worse? …..The ACA specifically protected against discrimination for pre-existing conditions that showed up through genetic tests. You might not be sick yet—in technical terms, the illness has not manifested—but if you, for example, test positive for one of the pathogenic variants (a less X-Manly term than “mutation”) in the BRCA gene that predisposes you to breast cancer, you could still get covered. If the House bill becomes law, that protection vanishes. “(A)
Here’s a primer:
“A pre-existing condition is a term insurance companies used before the Affordable Care Act, the healthcare law better known as Obamacare, to classify certain diseases or health problems that could cause a person to be denied coverage or make their coverage more expensive than that of people considered healthy.” (B)
“So what qualifies as a pre-existing condition under the bill? Nobody knows. The bill lacks any specifications, allowing health insurers a spacious margin for deciding who gets to pay through the nose for coverage.….Each of us is vulnerable to the unchecked exclusionary power that the health care bill would restore to the health insurance sector — a power that insurance providers have wielded before and used to devastating effect.” (C)
“Before Obamacare…..the patchwork of state and insurance regulations allowed each state to define pre-existing condition in its own way….”
Before Obamacare, along with significant diseases that were considered to be pre-existing like cancer, diabetes and heart disease, there were a variety of fairly minor conditions…other possible situations falling under pre-existing condition clauses are chronic conditions as acne, hemorrhoids, toenail fungus, allergies, tonsillitis, and bunions, hazardous occupations such as police officer, stunt person, test pilot, circus worker, and firefighter, and pregnancy and/or the intention to adopt. (D)(E)
“In the pre-Obamacare era, insurers were able to deny coverage outright to people with pre-existing conditions. The Affordable Care Act banned individual states from allowing insurers to charge people with pre-existing conditions at a higher cost.
Under the American Health Care Act, states can opt to allow individual insurers the discretion of deciding what does and not count as a pre-existing condition. While people with those pre-existing condition can’t be denied coverage, they can potentially be charged more.” (F)
So once again we “don’t know what we don’t know.” But we can speculate that health insurance applicants with pre-existing conditions might be “red-lined” by insurance companies and be quoted higher premiums up to five-times that paid by others, rates coupled with deductibles and co-pays that make policies unaffordable. (G)
aka the UNAFFORDABLE CARE ACT!
(A) The House Health Plan Makes Your Genes a Preexisting Condition by Adam Rogers, WIRED, https://www.wired.com/2017/05/house-health-plan-makes-genes-preexisting-condition/
(B) From acne to pregnancy, here’s every ‘preexisting condition’ that could get you denied insurance under Trump’s new healthcare bill, by Lydia Ramsey, Business Insider, http://www.businessinsider.com/what-counts-pre-existing-condition-ahca-trump-obamacare-2017-5
(C) Under The Republican Health Bill, We All Have Pre-Existing Conditions, by Miles Howard, WBUR, http://www.wbur.org/cognoscenti/2017/05/05/under-the-republican-health-bill-we-all-have-pre-existing-conditions
(D) What Is A Pre-Existing Condition Anyway? by Linda Bergthold, Huffington Post, http://www.huffingtonpost.com/entry/what-is-a-pre-existing-condition-anyway_us_590f60c8e4b046ea176aec7e
(E) What the GOP health care bill really says about pre-existing conditions by Tami Luhby, CNN, http://money.cnn.com/2017/05/01/news/economy/obamacare-trump-pre-existing-conditions/
(F) Pre-existing conditions: How 130 million Americans may be affected by the Obamacare repeal, by Christina Gregg, AOL, https://www.aol.com/article/news/2017/05/05/pre-existing-conditions-american-obamacare-repeal-american-health-care-act/22071483/
(G) The Republican Health Care Plan Is a Nightmare for the Old and Nearly Poor by Jordan Weissmann, Slate, http://www.slate.com/blogs/moneybox/2017/03/13/republican_plans_could_raise_insurance_premiums_by_750_percent_for_some.html