PART 2. May 20, 2019. OUT-OF-NETWORK BILLS. Private Equity is a Driving Force Behind Devious Surprise Billings

ASSIGNMENT: Draft the principles for federal “surprise bill” legislation

I thought I was a good OUT-OF-NETWORK detective and could avoid SURPRISE MEDICAL BILLS. Not so! Recently I switched physicians within a sub-specialty practice group. The first MD took my Medicare “GAP” insurance but the second did not. This lesson already cost me $1,000 versus an in network cost of probably $200. One can never be too vigilant!

New PART 2 after PART 1.

PART 1. July 29, 2018. SURPRISE MEDICAL BILLS.  Write in AS LONG AS THE PROVIDERS ARE IN MY NETWORK…before you sign any hospital admission documents accepting financial responsibility for your care.

“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 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.”(A)

A 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.” (B)

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?

– 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. (D)

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)

“Advocates for patients, senior citizens, labor unions, and businesses hailed Gov. Phil Murphy’s signing of a complex and controversial measure designed to curb the impact of costly “surprise” medical bills in New Jersey. Supporters said the law, nearly 10 years in the making, is the strongest of its kind nationwide…

The Democratic governor, who pledged his support for the bill in March, said the law closed a loophole to protect patients and make healthcare more affordable; sponsors called it the right thing to do to protect vulnerable residents. “We have put patients first. We have made clear that New Jersey stands for transparency when it comes to health care,” …

The reform is designed to protect patients, businesses, and others who pay for medical care from the high-cost bills associated with emergency or unintentional care from doctors or other providers who are not part of their insurance network. The law requires greater disclosure from both insurance companies and providers – so patients are clear on what their plan covers – ensures patients aren’t responsible for excess costs, and establishes an arbitration process to resolve payment disputes between providers and insurers, a mechanism intended to better control costs…

“It’s a solution that is fair to healthcare providers and consumers alike because it strikes a balance between providing reasonable compensation to facility-based providers, while protecting consumers from unexpected, nonnegotiable bills that drive health insurance premiums higher,” said NJBIA president and CEO Michele Siekerka. “This was an extremely difficult and complicated issue, and NJBIA commends the governor and the bill sponsors who worked hard to address the concerns of all stakeholders.”” (F)

A price transparency RFI released by the agency this week asks for input on how CMS might develop consumer-friendly policy. In a request for information announced Thursday, the Centers for Medicare & Medicaid Services asked whether providers and suppliers should be required to tell patients, in advance, how much a given healthcare service will cost out-of-pocket. If the agency were to move forward with a price transparency requirement on physician practices, it could prove controversial. Many doctors say they themselves lack the training they would need to have effective conversations about how much the healthcare services they provide will ultimately cost patients.

But CMS has repeatedly indicated that it aims to get more pricing information to consumers one way or another. “We are concerned that challenges continue to exist for patients due to insufficient price transparency,” the agency wrote in its RFI, which is included in proposed revisions to the Physician Fee Schedule, Quality Payment Program, and other policies for 2019…

In order to determine what additional actions may be appropriate to connect consumers with accessible price information, the CMS price transparency RFI includes a variety of questions, including the following:How should the phrase “standard charges” be defined in various provider and supplier settings?

Which information types would be most useful to beneficiaries, and how can providers and suppliers empower consumers to engage in price-conscious decision-making?

Should providers and suppliers have to tell patients how high their out-of-pocket costs are expected to be before providing a service?” (G)

“Patients are at a higher risk of receiving surprise medical bills on Affordable Care Act exchanges, according to a new report.

In 2018, more than 73% of plans available in the exchange marketplace offered restrictive networks, compared with 48% in 2014, according to the report (PDF) commissioned by Physicians for Fair Coverage. PFC is a nonprofit alliance of physician groups which advocates for ending surprise insurance gaps and improving patient protections…

“This research confirms what patients and physicians across the country have known for some time,” said PFC President and CEO Michele Kimball in a statement. “Insurers have been systematically narrowing their networks and increasing premiums, creating surprise insurance gaps that patients don’t realize exist until it’s too late. While insurers are making record profits, patients are paying more for less.”

The coalition, which includes tens of thousands of emergency physicians, anesthesiologists and radiologists from across the country, is pressing for more states to adopt legislation to solve the problem of surprise medical bills. The problem often occurs when a patient seeks care at an in-network hospital but is then surprised the doctor treating them is out of their insurance company’s network-a fact they usually find out when they get the doctor’s bill.

“When it comes to health care, nobody likes a surprise. This study confirms what we’ve been hearing from patients for years: there is no real way for patients to avoid a ‘surprise’ medical bill, even when they’re insured and try to stay in-network. We need a transparent healthcare system designed for patients, not profits,” Rebecca Kirch, executive vice president of healthcare quality and value at the National Patient Advocate Foundation, said in a statement…

The best estimates indicate that 1 out of 7 times someone goes to the emergency department, they are going to be stuck with a surprise bill.” (H)

A patient came to see me with lower abdominal pain. Was she interested in my medical opinion? Not really. She was told to see me by her gynecologist who had advised that the patient undergo a hysterectomy. Was this physician seeking my medical advice? Not really. Was this patient coming to see me as her day was boring and she needed an activity? Not really. After the visit with me, was the patient planning to return for further discussion of her medical status? Not really.

So, what was going on here. What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago.

The woman had pelvic pain and consulted with her gynecologist. An ultrasound found a lesion within her uterus. A hysterectomy was advised. The insurance company directed that a second opinion be solicited. A second gynecologist concurred with the first specialist. The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain. In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.

How should we respond? (I)

“In the absence of laws barring balance bills and surprise bills, there are steps hospitals and health plans can take to protect consumers from medical debt. The Healthcare Financial Management Association urges hospitals to inform patients that they may be eligible for financial assistance provided directly by the hospital and make clear to patients what services are and are not included in their price estimates. Hospitals also need to communicate better with uninsured patients about medical costs and options for sharing costs..

Health plan best practices include helping members estimate expected out-of-pocket costs and sharing price information for providers in a given region.

Beyond that, hospitals need to double down to ensure they have contracts with as many in-network providers as possible. “It requires the physicians, hospitals, health plans all working together to make sure that everybody’s in-network or, if they’re not, the patient knows that clearly up front,” says Rick Gundling, HFMA’s senior vice president for healthcare financial practices. “It’s kind of a three-legged stool.”

Consumers also need to become savvier when it comes to costs of medical care. Most people do see providers in their network, says Gupta. However, “because of their high-deductible health plan, they often don’t recognize until they get hit with a bill that the same MRI might be $3,000 after the deductible at a local hospital that is convenient for them versus $1,000 a mile down the street at an imaging center,” he adds.” (J)

“Cooper works as a physician assistant and hears about medical billing problems all the time.

So when she initially found out she was pregnant, this health care provider did everything she could to make sure anyone associated with her pregnancy would be considered what’s referred to as “in-network.”

She contacted her insurance company, Aetna, and she also contacted Banner Gateway Hospital, the hospital where she planned to give birth. The hospital then sent her written confirmation that she had nothing to worry about.

“She said, ‘Send me a picture of your insurance card front and back and I’ll double check that you’re covered.’ And, she sent me back an hour later saying, ‘Yes, you are in network,'” Cooper said.

Cooper eventually delivered her little girl at Banner Gateway Hospital. But, not long after, Cooper started getting a number of large “out-of-network” medical bills.

“Aetna then sent me back something that said, ‘No you are out-of-network’ and that’s how everything started to trickle through,” she said.

“Out-of-network.” How could that happen? Remember, she got written confirmation from Banner Gateway Hospital indicating she was “in-network.”…

When she added them all up, her medical bills came to around $18,000, money she shouldn’t have been responsible for. Still, she says she wasn’t getting any resolution…

We asked them to review Cooper’s case and after they did, they acknowledged there was a mistake.

As a result, Aetna reprocessed all of Heather’s bills as “in-network.”..

That means Cooper will now only have to pay just $750 out of pocket, the cost of her deductible rather than $18,000. Cooper said she couldn’t be happier and says it all happened with the help of 3 On Your Side.” (K)

“On the first morning of Jang Yeo-im’s vacation to San Francisco in 2016, her eight-month-old son Park Jeong-whan fell off the bed in the family’s hotel room and hit his head.

There was no blood, but the baby was inconsolable. Jang and her husband worried he might have an injury they couldn’t see, so they called 911, and an ambulance took the family – tourists from South Korea – to Zuckerberg San Francisco General Hospital.

The doctors at the hospital quickly determined that baby Jeong-whan was fine – just a little bruising on his nose and forehead. He took a short nap in his mother’s arms, drank some infant formula, and was discharged a few hours later with a clean bill of health. The family continued their vacation, and the incident was quickly forgotten.

Two years later, the bill finally arrived at their home: They owed the hospital $18,836 for the 3 hour and 22 minute visit, the bulk of which was for a mysterious fee for $15,666 labeled “trauma activation,” which sometimes is known as “a trauma response fee.”

Update: After this story was published on June 28, Zuckerberg San Francisco General Hospital agreed to waive the $15,666 trauma response fee charged for Park Jeong-whan’s visit to the hospital. In a letter, the hospital’s patient experience manager said the hospital did a clinical review and offered “a sincere apology for any distress the family experienced over this bill.” Further, the hospital manager wrote that the case “offered us an opportunity to review our system and consider changes.” (L)

“The health insurer Anthem is coming under intense criticism for denying claims for emergency room visits it has deemed unwarranted…

The insurer initially rolled out the policy in three states, sending letters to its members warning them that, if their emergency room visits were for minor ailments, they might not be covered. Last year, Anthem denied more than 12,000 claims on the grounds that the visits were “avoidable,” according to data the insurer provided to Senator Claire McCaskill, a Democrat from Missouri, one of the affected states.

But when patients challenged their denials, Anthem reversed itself most of the time, according to data the company gave Ms. McCaskill. The report concludes that the high rate of reversals suggests that Anthem did not do a good initial job of identifying improper claims, meaning some patients who did not challenge their denials may have been stuck paying big bills they should not have been responsible for.” (M)

PART 2. Private Equity is a Driving Force Behind Devious Surprise Billings,

 “The expectant mother was in labor at South Shore Hospital when she requested a common pain medicine, which was administered by an anesthesiologist. Home with a newborn days later, she was surprised when a bill arrived from the doctor’s group for $2,143.44.

Another patient who went to Emerson Hospital’s emergency department for what turned out to be a broken rib also received a surprise bill: $300.91, for the services of the doctor who read the X-ray…

Patients should not have to “contact their health plan and complain,’’ said David Seltz, executive director of the Massachusetts Health Policy Commission, which monitors health care spending in the state. “Through no fault of their own they are being put in this situation.’’

An analysis by the policy commission found that 10,000 Massachusetts patients in just one year may have received surprise bills for so-called out-of-network care, and policy experts believe that figure underestimates the extent of the problem…

More than 35 percent of complaints filed with Healey were over out-of-network charges, which can be up to 200 percent higher than what insurers pay in-network doctors. Among the physicians that were outside the patients’ insurance networks were anesthesiologists assisting in colonoscopies and emergency medicine doctors repairing broken bones and treating heart attacks, something that frustrated patients told Healey’s office they had no way of knowing in advance. Radiologists and pathologists also directly billed patients out-of-network charges.

It’s not unusual for a hospital to have practitioners working in their facilities who are not covered by all their agreements with insurers, a technicality that is often not apparent to patients.” (A)

“ (Trump)” In my State of the Union address, I asked Congress to pass legislation to protect American patients.  For too long, surprise billings — which has been a tremendous problem in this country — has left some patients with thousands of dollars of unexpected and unjustified charges for services they did not know anything about and, sometimes, services they did not have any information on.  They weren’t told by the doctor.  They weren’t told by the hospitals in the areas they were going to.  And they get, what we call, a “surprise bill.”  Not a pleasant surprise; a very unpleasant surprise.

So this must end.  We’re going to hold insurance companies and hospitals totally accountable.” (B)

“But physician advocacy groups, including the American Medical Association (AMA) while applauding the effort to eliminate surprise bills, expressed some concern that a simplified approach to a complex problem could have unintended consequences for healthcare delivery…

“We agree with the president that patients should not be responsible for coverage gaps and for any costs beyond their in-network cost sharing when they do not have an opportunity to choose an in-network physician,” said Barbara L. McAneny, MD, AMA’s president in a statement. “We also agree that physicians and hospitals should be transparent about their costs, and payers should offer transparency about their networks, scope of coverage, and out-of-pocket costs. In addition, insurers should be held accountable for their contributions to the problem and ensure network adequacy, adherence to the prudent layperson standard for emergency care in current law, and reasonable cost-sharing requirements.”” (C)

“Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR), the top Democrat and Republican on the House Energy and Commerce Committee, have jointly released a draft bill that would prevent patients from facing unexpected charges after they go to the emergency room or receive other non-emergency medical care…

The Pallone and Walden bill takes a multi-pronged approach to ending surprise medical bills:

Health insurers would be required to treat out-of-network emergency care as in network for their enrollee’s cost-sharing and out-of-pocket obligations. So patients wouldn’t have to pay any more for receiving emergency treatment at an out-of-network hospital than they would at an in-network one.

Balance billing — when a health care provider sends a patient a bill charging them whatever the difference is between the price set for a service by the provider and the price the health insurer is willing to pay — would be prohibited.

Insurers would have to make a minimum payment to out-of-network providers for their enrollee’s care, based on the price the insurer pays to nearby in-network providers… (D)

“These protections would apply to all out-of-network emergency services and to all out-of-network nonemergency services received at an in-network facility from “facility-based providers,” which the bill defines to include anesthesiologists, radiologists, pathologists, neonatologists, assistant surgeons, hospitalists, intensivists, and any additional provider types specified by the Secretary of Health and Human Services (HHS). Other provider types would still be allowed to treat patients on an out-of-network basis in nonemergency situations if they met the strong notice and consent requirements detailed in the discussion draft. Limiting notice and consent exceptions to physician specialties that patients typically actively choose strikes a sensible balance. It preserves patients’ ability to seek out-of-network care in circumstances where it is appropriate, while mitigating the risk that the flood of paperwork involved in seeking medical care will result in some patients consenting to out-of-network billing without understanding what they are consenting to or whether they have a reasonable alternative.” (E)

“A new draft bill released this morning sets up a so-called “baseball-style” arbitration process for providers and plans as an option to settle payment disputes, POLITICO’s Rachel Roubein writes. Today’s draft comes after Sens. Bill Cassidy (R-La.), Michael Bennet (D-Colo.) and four others spent eight months refining legislation first introduced in September. More for Pros.

— Today’s legislation prohibits balance billing in three instances, Rachel writes. (1) For emergency care, (2) during elective care at an in-network facility but when a service is performed by an out-of-network provider and (3) when a patient needs additional medical care after an emergency at an out-of-network facility but can’t travel elsewhere.

— The most contentious part of addressing surprise medical bills: the payment. Under the new bill, providers would automatically be paid the median in-network rate. But they can dispute that, initiating a so-called “baseball-style” arbitration process, where mediators will base decisions on “commercially reasonable rates” (the in-network rates for that area and not actual charges).” (F)

“The House of Representatives and the Senate have unveiled dueling legislation aimed at surprise billing, and the two are split on one key element: arbitration.

The House bill (PDF), which was introduced earlier this week by Reps. Frank Pallone, D-New Jersey and Greg Walden, R-Oregon, would require insurers to cover out-of-network emergency care at in-network rates and would ban balance billing.

Balance billing most often occurs in emergency departments or during elective surgery, when a patient goes to an in-network facility but is treated by an out-of-network clinician, typically an anesthesiologist or radiologist.

The Senate’s bill, however—which is backed by Sens. Bill Cassidy, R-Louisiana, and Maggie Hassan, D-New Hampshire—would include a “baseball-style” arbitration program to mitigate disputes, alongside similar elements to the House iteration.” (G)

“The administration said its top priority is to make sure patients no longer receive separate bills from out-of-network doctors, an approach known as a “bundled payment.”..

Vidor Friedman, president of the American College of Emergency Physicians, said a bundled payment puts too much pressure on hospitals to contract with physicians, essentially making hospitals take on the role of insurer.

“It would create another layer between the patient and providers of care,” Friedman said, noting that doctors would need to negotiate directly with hospitals for payment, rather than with insurance companies…

Instead, doctors and hospitals want an independent arbitrator to examine the amount the doctor is charging and what the insurer is agreeing to pay — and then determine which one is fairer…

But insurers are opposed to arbitration, and they’re pushing for Congress to set reimbursement rates.

In a letter to House and Senate leaders in March, America’s Health Insurance Plans urged lawmakers to “avoid the use of complex, costly and opaque arbitration processes that can keep consumers in the middle and lead to higher premiums.”

The White House also threw cold water on arbitration. During a briefing with reporters on Thursday, administration officials called arbitration an “unnecessary distraction.”..

 “Providers point fingers at payers, payers point fingers at providers, and the American people are left really getting the shaft,” a senior administration official said.

The White House and lawmakers have been warning all the players to solve the problem on their own. But now with pressure from the White House, Congress is likely to act.

“There will come a point in time when they want to move a solution forward,” AHA’s Smith said. “It’s unlikely you’ll come to a solution where every one of the stakeholders is happy.”” (H)

“One of the major drivers of surprise bills is the deliberate decision by health insurance plans to narrow the networks of providers available to their insureds—core network adequacy requirements should be an essential component of any solution,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in the letters to committee leaders. “Shrinking networks increase the likelihood that patients may receive care from an out-of-network provider, particularly in emergency situations.”

..Patients are shouldering more of the costs through larger deductibles and higher copays. The median out-of-network deductible for individual marketplace is $12,000 and almost a third of individual market plans have deductibles of more than $20,000 according to research by the Robert Wood Johnson Foundation cited in the letter.

“Limited networks of providers and unaffordable deductibles for care outside those networks can expose patients to high out-of-pocket costs,” Dr. Madara wrote.

..Often insurance companies will use tactics such as prior authorization or “fail-first” step therapy protocols to make patients pay out of pocket for medically necessary treatment they refuse to cover.

.. Despite federal mental health-parity requirements, patients can feel squeezed by their health plans when it comes to mental health and substance-use disorder treatments—and that leads to a greater reliance on out-of-network care…

..Some insurance companies have enacted policies of not paying for emergency care after it was determined that patients did not require it—even though the severity of their symptoms at the time made it prudent to go to the nearest emergency department.

..Insurance companies often change their drug formularies after patients are locked into their plan. This can lead to restricting access to treatment that has proven to work for them and has stabilized their condition. Patients may seek to pay out of pocket to continue their treatment rather than jump through their insurance company’s prior-authorization hoops.” (I)

“Surprise medical bills exist for a number of reasons, each of which are specifically rooted in problems inherent to a privatized, profit-driven health-care system. For one thing, there wouldn’t be out-of-network bills without networks themselves—a health insurance innovation put forward in the 1980s. Unlike more regulated health-care systems in peer nations, the American health-care system lacks a robust mechanism to control prices. This leaves each insurance plan to negotiate with providers on its own, and gives the latter more power to set prices.

Once health-care prices began to skyrocket in the 1970s, insurance companies began to try several cost-cutting measures that are now all too familiar to modern policyholders…The theory behind networks was simple enough: By contracting only with certain providers, insurers could deliver a higher volume of patients to each one and thereby gain more leverage over pricing negotiations. They could then translate the savings into lower premiums, attract more customers, and increase market share…

..and it’s the same problem underlying the proliferation of varied “insurance products” that cater to different types of patients. The degree of “choice” a given person has is overwhelmingly determined by their income and health status, which is a shamefully unjust way to allocate the costs of running a health-care system. The healthiest people are able to take their chances on a narrow network, while those with greater health-care needs are financially penalized for needing a wider breadth of providers. Meanwhile, the less money someone has available, the more they’re coerced into “choosing” a plan based on price rather than benefits…

Discussing and tackling the inequities—and potential for financial ruin—in our health-care financing system demands an acknowledgment that the sheer diversity of insurance plans in this country, each with their own pricing and benefit structures, is an inherently bad thing. When it comes to insurance policies, a multitude of consumer choices translates into genuine differences in the ability to access care. “Surprise out-of-network bills” are one highly visible example of how that hurts people. Others are never hard to find.” (J)

“While President Donald Trump prods Congress to limit surprise billing, at least three states are debating legislation to ban the practice…

Current state laws vary in scale and effectiveness. Federal legislation would be more effective, as it would protect the millions who receive self-funded coverage through their employer. But the political climate in Washington, where even historically bipartisan efforts move slowly at best, has left states to step in and do what they can…

The Colorado General Assembly passed a bill earlier this month that prohibits surprise billing and sets a reimbursement rate based on either commercial claims data or the insurers’ median in-network rate for the service. Gov. Jared Polis, a Democratic, is expected to sign the bill Tuesday, a spokesman told Healthcare Dive.

A surprise billing law is also on the governor’s desk In Washington. It calls for a “commercial reasonable amount” to be paid to out-of-network providers and establishes arbitration if the parties cannot agree on a rate through negotiation.

In Texas, a bill has passed the Senate and is currently making its way through the House. It requires an arbitration process for payments that do not include patient involvement. Previous legislation in the state required people receiving surprise bills to request remediation…

The Employee Retirement Income Security Act of 1974 limits the effectiveness of state surprise billing legislation because state laws can’t apply to employer self-funded plans, which cover the majority of Americans. Still, the laws can serve a few key purposes.

Several of the bills proposed in Congress defer to state laws on issues like rate setting or arbitration. So even if Washington passes a ban on surprise billing, states that want to set their own plans can count on using their own laws going forward…

“States have a lot of authority over providers … just making sure the providers have posted information and are being as informative as possible when consumers are coming into their facilities,” she said.” (K)

Arizona’s new law on surprise medical bills went into effect January 1. It sets up a procedure where patients can request dispute resolution through the state’s Department of Insurance. Unresolved disputes will enter arbitration. If an enrollee participates in an informal settlement teleconference (IST) beforehand, the law spells out what an enrollee’s liability: “By virtue of having participated in the IST, the enrollee can only be held responsible for paying the amount of the enrollee’s cost-sharing requirements (copay, coinsurance and deductible) plus any amount the health insurer paid the enrollee for the services provided by the out-of-network health care provider.” (L)

“Consumer complaints about surprise medical bills have fallen substantially in New York in the wake of a 2014 law that established a “baseball-style” arbitration protocol to address these situations, according to a new report.

Researchers at the Georgetown University Center on Health Insurance Reforms (CHIR) conducted a case study (PDF) on the state’s Emergency Services and Balance Billing Law and found that state officials report a “dramatic” decline in consumer reports about balance bills since the law took effect in 2015.

Based on an analysis of calls to the Consumer Service Society’s helpline for surprise billing, 57% of complaints were handled using the systems established under the law.

 “It’s downgraded the issue from one of the biggest [consumer complaints our call center receives] to barely an issue,” a state regulator told the CHIR researchers.

In addition to surveying state officials, the Georgetown researchers also interviewed physicians, insurers and patients, and they found that overall the participants view the arbitration process as fair. However, providers were more enthusiastic than insurers, according to the study.

As of October, the number of resolutions in favor of insurers and in favor of physicians is about even, according to the study—618 were decided in favor of payers and 561 in favor of providers. 

Insurers were more likely to win disputes over out-of-network emergency care billing, while providers were more likely to win in situations where a patient is treated by an out-of-network physician without his or her knowledge during an elective procedure.” (M)

“The American Hospital Association was among six national hospital groups that sent a letter to Congress on Wednesday to suggest parameters and ideas that legislators should keep in mind as they pursue a solution to surprise medical bills…

The letter to Congress, a copy of which was obtained by ROI-NJ, asks federal representatives to consider:

Defining what is considered a surprise bill;

Ensuring patients are protected and not balance billed;

Ensuring patients are not denied emergency coverage if a visit is considered non-emergent in retrospect;

Avoiding setting a fixed payment rate;

Ensuring patients are educated about their rights and coverage;

Supporting state laws (like those in New Jersey) that are protecting consumers.”  (N)

“Assemblyman Nick Chiaravalloti is planning to introduce legislation in May that would plug a loophole in the (New Jersey) out-of-network law that has been affecting patients transferred out of state…

Health care professionals would be required to document in the patient records and notify patients of

The patient’s right to receive care at a facility of choice;

Clinical rationale for the out-of-state transfer;

Location of the out-of-state facility;

Availability of clinically appropriate services at nearby New Jersey facilities;

The nature of the relationship if the patient is being transferred or referred to an affiliated facility; and

In instances of trauma, stroke or cardiovascular diagnoses, an explanation as to why the patient is not being transferred to a facility in New Jersey.

The bill also requires patients be provided information from their insurance providers as to their potential out-of-pocket costs for an out-of-state facility, and requires health facilities to disclose to patients their relationships with out-of-state providers the patients are being referred to.

This is particularly important with the recent merger activity in South Jersey with some hospitals tied to health systems in Pennsylvania…

 “To ensure that health care consumers are able to make well-informed health care decisions, patients should be informed of their right to select the facility in which they receive their care before being transferred to another state,” he said. “Patients should have all the information about why they are being transferred, and their financial responsibilities associated with the transfer — only then can a patient make an informed choice.” (O)

“One of the many wonderful advantages we have as residents of New Jersey is access to high quality, advanced health care. In fact, more than half of New Jersey’s 67 acute-care hospitals received an “A” rating in the Leapfrog Hospital Safety Report, the highest percentage of “A” ratings in any state across the nation. New Jersey is also home to tremendously skilled physicians and nurses, as well as 13 academic health systems training the next generation of health care professionals and researchers. Clearly, New Jersey residents have access to some of the nation’s greatest health care resources.

Despite these facts, a significant number of patients are referred or transferred to health care providers and hospitals located out of state. Some estimates indicate that New Jersey residents spend more than $2 billion annually on health care services out of state. Often these patients are paying considerably more for their out-of-state health care and receiving care that is equal to or less effective than they could have received at hospitals in New Jersey. With health care consumers paying a larger percentage of their health care costs through higher deductibles, copayments, and coinsurance, paying more for the same quality of care further from home makes little sense.

New Jersey residents should have the right to obtain health care wherever they believe it is best, but often patients do not have critical information necessary to make an informed decision. Moreover, many New Jersey residents do not understand the strong consumer protections they are forfeiting by seeking care outside of the state.” (P)

“Bob Ensor didn’t see the boom swinging violently toward him as he cleaned a sailboat in dry dock on a spring day two years ago. But he heard the crack as it hit him in the face.

He was transported by ambulance to an in-network hospital near his home in Middletown, N.J., where initial X-rays showed his nose was broken as were several bones of his left eye socket. The emergency physician summoned the on-call plastic surgeon, who admitted him to the hospital and scheduled him for surgery the next day.

Shortly before surgery, the doctor introduced Ensor to a second plastic surgeon who would assist in the 90-minute procedure. Entering through Ensor’s nose, the physicians realigned his facial bones, temporarily sewing Ensor’s left eye shut so that the lids would stay in place as the bones knitted back together.

Six weeks later, as Ensor, then 65, continued to make an uneventful recovery, a collection agency called to inquire how he and his wife planned to pay the $71,729 bill for the assistant surgeon. Ensor’s company health plan had denied payment because the surgeon wasn’t part of its contracted physician network.

There was more bad news. Ensor received notice that the health plan wouldn’t cover the $95,885 charged by the first plastic surgeon either because he also was out-of-network.

“The hospital knew these doctors were out-of-network and didn’t bother to tell us,” said his wife, Linda Ensor, noting they faced more than $167,000 in charges. “We were panicked.”

Riverview Medical Center in Red Bank, N.J., where Ensor was treated, said that it “empathizes with patients who are trying to navigate the complexity of the health care billing system” and that transparency in billing has not always been optimal for emergency department patients…

Many plastic surgeons don’t participate in health plans because they have flexibility other physicians may not have — their practices often focus on elective cosmetic procedures like nose reshaping and breast augmentation that patients pay for on their own…

Luckily for the Ensors, the sailing club stepped in to take up his case with the out-of-network plastic surgeons. Since sailing club members were required to volunteer on work projects to keep membership costs in check, the club’s insurer agreed to cover the accident as a workers’ compensation case. It paid 100% of the outstanding bill.” (Q)

“In an email to a complaining patient, the CEO of Spectrum Health acknowledged there needs to be more transparency regarding how patients are billed for doctor visits.

“We agree with you that a more transparent process is necessary,” Spectrum Health CEO Tina Freese Decker wrote (PDF) in response to a complaint. “I have shared your suggestion (for additional transparency) with our Spectrum Health Medical Group leadership so that we can apply this suggestion into our workflow.”..

The patient who sent the email to the CEO — and shared the response with Target 8 — had been charged $142 for a second appointment because she briefly discussed two minor issues with her doctor during her annual exam…

A month later, the patient received her bill. The annual wellness visit was covered by insurance, but there was a second charge for the same day that was not covered…

Additionally, a single mother from a small town in Kent County, who Target 8 is identifying only as Lindsey, previously reached out to Target 8 regarding a bill she got after a wellness visit with a physician at Spectrum medical building in Grand Rapids. While she waited for the appointment, Lindsey filled out the standard questionnaire, checking a box to indicate she had periodic leg cramps.

“(The doctor) looked at the form and she said, ‘Oh, I see you checked yes to leg cramps. Tell me more about it,’” Lindsey recalled.

Lindsey said the doctor showed her some stretches, told her to drink more water and checked her magnesium and iron levels in addition to the routine blood tests that were already scheduled for her annual physical.

“I get the bill… and I was charged for two office visits,” Lindsey said in an interview with Target 8 Thursday. “I called the doctor’s office right away and I said, ‘This can’t be right. Is this a mistake?’”

But it wasn’t a mistake…

If you’re going in for preventive services, know that there is a scope of services that’s considered preventive with zero cost, but if you go in and have a complaint or a scenario diagnosed, then it changes… to another category of care,” ”.. (R)

“Yale researchers Zack Cooper and Fiona Scott Morton looked at emergency department visits that occurred at hospitals that were in insurers’ networks, in a paper for the New England Journal of Medicine. “On average,” they found, “in-network emergency-physician claims were paid at 297% of Medicare rates,” while “out-of-network emergency physicians [within in-network hospitals] charged an average of 798% of Medicare rates.”

A study from UnitedHealthGroup, looking at its own claims nationwide, recently estimated that out-of-network emergency physicians increased health care charges by $6 billion per year.” (S)

What’s behind this explosion of outrageous charges and surprise medical bills? Physicians’ groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians’ practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms…

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies — EmCare and TeamHealth — took over hospital ERs. They found:

“…that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.”

TeamHealth used the threat of sending high out-of-network bills to the insurance company’s covered patients to gain high fees as in-network doctors. The researchers found:

“…in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.”

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines. (T)

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PART 2. May 13, 2019. CANDIDA AURIS. “In 30 years, I’ve never faced so tough a reporting challenge — and one so unexpected. Who wouldn’t want to talk about a fungus?…

New PART 2 after PART 1.

PART 1. April16, 2019. Assignment: it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive – the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.”” (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected-someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases – now the third-highest after New York and Illinois – has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials…

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.” (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.” (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts – funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention – are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.”  (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.”  (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent…

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital – or an entire town – who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois – all in the Chicago area – a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities – such as skilled-care nursing homes or long-term acute-care hospitals – and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…” (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention – the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively – infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible – the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida – the regular ones – are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).

PART 2. In 30 years, I’ve never faced so tough a reporting challenge — and one so unexpected. Who wouldn’t want to talk about a fungus?…

“C. auris is a drug-resistant fungus that has emerged mysteriously around the world, and it is understood to be a clear and present danger. But Connecticut state officials wouldn’t tell us the name of the hospital where they had had a C. auris patient, let alone connect us with her family. Neither would officials in Texas, where the woman was transferred and died. A spokeswoman for the City of Chicago, where C. auris has become rampant in long-term health care facilities, promised to find a family and then stopped returning my calls without explanation.” (A)

“Candida auris, also referred to as C. auris, is a potentially deadly fungal infection that appears to be making its way through hospitals and long-term care facilities across the country. The New York City area and New Jersey have reported more than 400 cases over the last few years alone. Federal health authorities have declared this fungus a “serious global health threat.”” (B)

“The Council of State and Territorial Epidemiologists (CSTE) says Candida auris infections have been “associated with up to 40% in-hospital mortality.”

“Most strains of C. auris are resistant to at least one antifungal drug, one-third are resistant to two antifungal drug classes, and some strains are resistant to all three major classes of antifungal drugs. C. auris can spread readily between patients in healthcare facilities. It has caused numerous healthcare-associated outbreaks that have been difficult to control,” the CSTE said.

The CDC added, “Patients who have been hospitalized in a healthcare facility a long time, have a central venous catheter, or other lines or tubes entering their body, or have previously received antibiotics or antifungal medications, appear to be at highest risk of infection with this yeast.”

The CDC is alerting U.S. healthcare facilities to be on the lookout for C. auris in their patients.” (C)

“”It’s a very serious health threat,” said Dr. Irwin Redlener, Columbia University professor and an expert on public health policy. “It’s a superbug, meaning resistant to all-known antibiotics.”..

“These people would be in danger, so you don’t want somebody visiting the hospital not knowing that it’s around and somehow contracting the infection,” Dr. Redlener said. “That would be an utter disaster.”..

Dr. Redlener says the secrecy is a big mistake.

“If they’re rattled by Candida auris to the point where we have secrecy pacts among hospitals and public health agencies, then you’re just hiding something that obviously needs more attention and resources to deal with,” he said.

The state Department of Health says there is no risk to the general public and notes that the vast majority of patients have had serious underlying medical conditions.

Jill Montag, a spokesperson for the New York State Department of Health, issued a statement to Eyewitness News.

“We are working aggressively with impacted hospitals and nursing homes to implement infection control strategies for Candida auris,” it read.

Montag says they plan to include the name of the impacted facilities in their annual infection report, which will be released later this year.

Dr. Redlener says they have the information now and should release the names now…

“To keep that a secret is putting people in danger,” he said. “And I don’t think that’s reasonable or ethical.”” (D)

 “We don’t know why it emerged,” said Dr. Maurizio Del Poeta, a professor of molecular genetics and microbiology at Stony Brook University’s Renaissance School of Medicine. At the very least, he is recommending hospitals develop stricter rules on foot traffic in and out of patients’ rooms because the microbe can be carried on the bottom of shoes.

The pathogen clings to surfaces in hospital rooms, flourishes on floors, and adheres to patients’ skin, phones and food trays. It is odorless, invisible — and unlikely to vanish from health care institutions anytime soon.

“It can survive on a hospital floor for up to four weeks,” Del Poeta said of C. auris. “It attaches to plastic objects and doorknobs.”..…

 “If we don’t want it to become like Staphylococcus aureus, then we have to act now,” said Del Poeta, referring to the bacteria that became the poster child of drug resistance when it developed the ability to defeat the antibiotic methicillin, garnering the name methicillin-resistant Staphylococcus aureus, or MRSA…

 “In order to get Candida auris out of a room, you have to take away everything — doorknobs, plastic items, everything. It is very difficult to eradicate it in a hospital,” Del Poeta said. He said his institution has never had a patient with C. auris…

Scientists such as Del Poeta contend it’s time for new methods of addressing resistant microbes of all kinds because infectious pathogens have developed the power to outwit, outpace and outmaneuver humankind’s most potent agents of chemical warfare, many of them developed in the 20th century.” (E)

“A case management program piloted by the New York City health department monitors patients colonized with Candida auris after they are discharged into the community and notifies health care facilities of their status, researchers reported at the CDC’s annual Epidemic Intelligence Service conference….

Patients can remain colonized with C. auris for months in a health care setting, but it is unclear if they remain colonized after discharge, noted Genevieve Bergeron, MD, MPH, an Epidemic Intelligence Service officer with the New York City Department of Health and Mental Hygiene (DOHMH), and colleagues.

According to Bergeron and colleagues, the state health department began referring patients colonized with C. auris to the DOHMH on Oct. 4, 2017. Approximately 12 case managers handled the referrals, conducting patient interviews and reviewing medical records to obtain relevant clinical information. They informed the patients’ providers and health care facilities about their C. auris status and infection control needs.

“We requested that facilities flag the patient in their electronic medical records to ensure that the patient has the proper precautions, if the patient were to seek care again at those facilities,” Bergeron said in a presentation. “Case mangers sent a medical alert card to the patients for them to use when encountering health care providers unaware of their infection control needs.”” (F)

“Regions are considering the use of electronic registries to track patients that carry antibiotic-resistant bacteria including carbapenem-resistant Enterobacteriaceae (CRE). Implementing such a registry can be challenging and requires time, effort, and resources; therefore, there is a need to better understand the potential impact…

When all Illinois facilities participated (n=402), the registry reduced the number of new carriers by 11.7% and CRE prevalence by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n=304), registry use resulted in a 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and non-participating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n=201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. When 25% participated (n=101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and non-participating facilities, respectively) and 2.8% relative reduction in prevalence.

Implementing an XDRO registry reduced CRE spread, even when only 25% of the largest Illinois facilities participated due to patient sharing. Non-participating facilities garnered benefits, with reductions in new carriers.” (G)

“Quebec public-health authorities are bracing for the inevitable arrival of a multi drug-resistant fungus that has been spreading around the globe and causing infections, some of them fatal…

 “We will definitely have cases here and there at one point,” said Dr. Karl Weiss, chief of infectious diseases at the Jewish General Hospital. “It’s almost guaranteed. The only thing is when you know what you’re fighting against, it’s always easier and we will be able to contain it a lot faster.”

C. auris poses a quadruple threat: it’s tricky to identify; it can thrive in hospitals for weeks (preying on patients with weakened immune systems); it’s resistant to two classes of anti-fungal medications; and it can cause invasive disease, with lingering bloodstream infections that are hard to treat. The mortality rate can rise as high as 60 per cent.

The pathogen has emerged at a time when hospitals in Quebec — their budgets stretched more than ever — are already struggling with antibiotic-resistant superbugs like C. difficile, MRSA and VRE that have caused outbreaks. The Institut national de santé publique du Québec published a bulletin last year on steps that hospitals and long-term centres can take to prevent C. auris outbreaks.

“The problem is if you don’t identify the fungus properly, then it can slip in between your hands, and you can have an outbreak in your institution without even knowing it,” Weiss explained.

There was a lot of mis-indentification of this with other Candida (fungi); and even the automated systems in institutions that identify bacteria and yeast were mislabelling this Candida for something else. For a while, people were not aware of this auris. But now we know how to identify it.

“The first thing we did in Quebec — and this was for all the microbiology labs — is we taught all the microbiologists how to properly identify Candida auris,” Weiss continued.  “All the major labs in Quebec put in place protocols.”

Weiss, who is president of the Quebec Association of Medical Microbiologists, noted that under a quality assurance program, samples have been sent to different labs to test whether the fungus is identified correctly. The results show that that labs are detecting C. auris to a high degree.

If a patient is discovered to be infected, hospital protocol dictates that the patient be isolated. During the patient’s hospitalization, the housekeeping staff must disinfect the room daily with hydrogen peroxide and other chemicals…”  (H)

“Federal officials should declare an emergency over a deadly, incurable fungus infecting people in New York, New Jersey and across the country, Sen. Chuck Schumer said Sunday.

Schumer said he’s pushing the federal government to allocate millions of dollars to fighting Candida auris, which is drug-resistant and proving very difficult to eradicate…

“When it comes to the superbug, New York could use a little more help,” said Schumer. “The CDC has the power to declare this an emergency and automatically give us the resources we need.”..

Schumer said that an emergency declaration by the CDC would lead to more cases being identified with better testing, and to better tracking of the disease. It might also reduce the number of unnecessary antibiotic prescriptions, which Schumer says have helped the disease become drug-resistant…

Schumer cited other CDC emergency declarations that helped stop the spread of deadly diseases, including a $25 million award to fight the Zika virus in 2016 and $165 million given to contain Ebola in 2014.

“Every dollar we can use to better identify, tackle and treat this deadly fungus is a dollar well spent,” Schumer said.” (I)

“Other medical experts see the overuse of human antifungal medications in agriculture and floriculture as potential reasons for resistance in Candida auris, known as C. auris, and possibly other fungi.

Dr. Matt McCarthy, a specialist in infectious diseases at Weill Cornell Medicine in Manhattan, said tulips, signature flowers of the Netherlands, are dosed with the same antifungal medications developed to treat human infections.

“Antifungals are pumped into tulips in Amsterdam to achieve flawless plants,” he said. “As a fungal expert, I know that we have very few antifungal medications, and this is a misuse of the drugs.”

Studies conducted at Trinity College in Ireland support McCarthy’s argument and have demonstrated that tulip and narcissus bulbs from the Netherlands may be vehicles that spread drug-resistant fungi.

Trinity scientists, who examined resistance in another potentially deadly fungus, Aspergillus fumigatus, uncovered why the bugs repelled the drugs known as triazoles. The fungi became resistant because of the overuse of triazoles in floriculture. As with C. auris, drug-resistant A. fumigatus can be deadly in people with poor immunity.

When patients need treatment with triazole-class medications, the drugs don’t work because the fungi have been overexposed in the environment, McCarthy said.

He added that the use of antifungal medications in floriculture is similar to the overuse of antibiotics in the poultry and beef industries, which have helped drive resistance to those drugs.

The floriculture example is just one way that drug-resistant fungi can spread around the world. Global trade networks, human travel and the movement of animals and crops are others.”  (J)

“It will take further research to determine if the new strains of C. auris have their origins in agriculture, but Aspergillus has already illustrated the perils of modern farming. Antibiotics are applied on a massive scale in food production, pushing the rise of bacterial drug resistance. A British government study published in 2016 estimated that, within 30 years, drug-resistant infections will be a bigger killer than cancer, with some 10 million people dying from infections every year.

We don’t have to end up there. Pesticide use on most farms can be greatly reduced, or even eliminated, without reducing crop yields or profitability. Methods of organic farming, even as simple as crop rotation, tend to promote the growth of mutualistic fungi that crowd out pathogenic strains such as C. auris. Unfortunately, because conventional agriculture is heavily subsidized and market prices don’t reflect the costs to the environment or human health, organic food is more expensive and faces an uphill battle for greater consumption.

Of course, improved technology could help, with drugs of new kinds or in breeding and engineering resistant strains of plants. There’s also plenty of opportunity for lightweight agricultural robots, which can weed mechanically or spray pesticides more accurately, reducing the quantity of chemicals used. But tech shouldn’t be the sole focus just because it happens to be the most profitable route for big industries.” (K)

“The recent outbreak of the so-called superbug — and other drug-resistant germs — has thrown a spotlight on locally based Xenex Disinfection Systems. The company makes a robot that uses pulsing, ultraviolet rays to disinfect surgical suites and other environments that are supposed to be germ-free.

With the spread of C. auris, Xenex officials say they’ve seen an uptick in queries about their LightStrike Germ-Zapping Robots, which are in use at more than 400 health-care facilities around the world since manufacturing started in 2011.

These devices — often called R2Clean2, Mr. Clean and The Germinator — disinfect rooms in a matter of minutes. A dome on the top of the robot rises up, exposing a xenon bulb that emits UV light waves that kill germs on contaminated surfaces.

Bexar County-owned University Hospital has a fleet of six Xenex robots. One of the robots is assigned to the Cystic Fibrosis Center to help protect patients from infection by other patients.

“We are taking every measure possible to reduce the risk of infections, and this is an additional layer of security that bathes the room in UV-C light,” said Elizabeth Allen, public relations manager at University Health System…

Another study, recently published by a doctor at the Minnesota-based Mayo Clinic, showed that when the hospital used the robots in rooms that had already been cleaned, infection rates of another superbug — called Clostridium difficile, or C. diff — fell by 47 percent.” (L)

“It wasn’t publicized locally, but within the past few years teams of health officials at two Oklahoma health facilities took rapid actions to contain the spread of a fungal “superbug” that federal officials have declared a serious global health threat.

Only one patient at each facility was infected, and both patients recovered. But the incidents reflect the growing alarm among health officials over the deadly, multidrug-resistant Candida auris, or C. auris, which can kill 30 percent to 60 percent of those infected…

In April 2017, a team of experts from the federal Centers for Disease Control and Prevention converged on the University of Oklahoma Medical Center in Oklahoma City after a patient tested positive for the drug-resistant fungus.

About a year later, a patient at a southeast Oklahoma health facility tested positive for the germ during a routine test. In both cases, health officials isolated the patients, locked down their rooms and ordered dozens of lab tests to see if the multidrug-resistant fungus had spread…

Unlike with outbreaks in Illinois, New York and New Jersey, the potentially deadly infection was quickly contained.”..

Public knowledge about the OU Medical Center case makes it an exception. Typically, health care facilities across the nation don’t release to the public information when C. auris and other drug-resistant pathogens are found. No law or policy requires them to do so.

Patient-rights advocates maintain that the public has the right to know when and where outbreaks or even single cases occur. But health officials have routinely fought back, suggesting that it could violate patient rights and discourage patients from seeking hospital care.

But the CDC allows states to make that decision.

Burnsed said the Department of Health tries to walk a tight line between notifying the public and protecting the patient’s privacy.

He said he would be more likely to identify a facility if it’s anything more than an isolated case or if officials believed the exposure wasn’t contained.

“What we consider is if there was a risk to a broader group of individuals and if there was any evidence that there were a breach in lab controls,” Burnsed said. “We didn’t put out anything at the time (on Oklahoma’s two cases) because we didn’t think there was a greater risk to the public, but it’s a good question to consider.”” (M)

“How many people will needlessly die from a deadly bug sweeping through New York hospitals and nursing homes before local health officials acknowledge the danger publicly — and act accordingly?..

Yet public-health officials here have been slow to let patients know in which hospitals the bug is lurking. Folks are left to take their chances. That’s outrageous.

Why are officials mum? Partly because they fear that if they disclose the information, some people who need treatment won’t go for it.

That’s a weak excuse: As McCaughey notes, there are plenty of local hospitals that aren’t plagued by Candida auris, so patients could get care and avoid the risk, if they know where it’s safe to go.

More likely, no one wants to damage the reputations (or incomes) of the affected hospitals. Yet the best way to protect those reputations is to make sure the facilities are Candida auris-free…

Meanwhile, officials say they will reveal which hospitals have the germ — in their next yearly report. But that could be months away; patients need to know now.

If neither the hospitals nor their government regulators are willing to move sooner, perhaps state lawmaker should step in and require them to do so… (N)

Infectious disease experts tell Axios they agree with a dire scenario painted in the UN report posted earlier this week saying that, if nothing changes, antimicrobial resistance (AMR) could be “catastrophic” in its economic and death toll.

Threat level, per the report: By 2030, up to 24 million people could be forced into extreme poverty and annual economic damage could resemble that from the 2008–2009 global financial crisis, if pathogens continue becoming resistant to medications. By 2050, AMR could kill 10 million people per year, in its worst-case scenario.

“There is no time to wait. Unless the world acts urgently, antimicrobial resistance will have disastrous impact within a generation.”..

By the numbers: Currently, at least 700,000 people die each year due to drug-resistant diseases, including 230,000 people from multidrug-resistant tuberculosis, per the UN. Common diseases — like respiratory infections, STDs and urinary tract infections — are increasingly untreatable as the pathogens develop resistance to current medications.

The Centers for Disease Control and Prevention says AMR causes more than 23,000 deaths and 2 million illnesses in the U.S. annually…

What needs to be done: Jasarevic says the economic and health systems of all nations must be considered, and targets made to increase investment in new medicines, diagnostic tools, vaccines and other interventions.”

The bottom line: Action must be taken to avoid a catastrophic future.” (O)

“A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.

Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.

What many might not realize, though, is that health care workers’ attire — including that seemingly “clean” white coat that many prefer — can harbor dangerous bacteria and pathogens.

A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.”

It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.

Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours…

It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers — including wearable sanitizer dispensers — could help reduce the spread of harmful bacteria.

Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.” (P)

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“The longer these (measles) outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States.”

PART 1. April 30, 2019

PART 2. May 6, 2019. “We are getting very close to a tipping point. If (measles) cases continue to escalate, the U.S. could lose its elimination status…”

Assignment: Develop a continuum of evidenced based strategies for states focusing on avoiding measles cases (22 states are already “infected”)

New PART 2 after PART 1

PART 1. April 30, 2019

“The longer these (measles) outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States.”

“The number of measles cases in the United States has risen to 695, the highest annual number recorded since the disease was declared eliminated in this country in 2000, federal health officials said on Wednesday.

The total has now surpassed the previous high of 667 set in 2014, according to the Centers for Disease Control and Prevention. The virus has been detected in 22 states.

Most cases are linked to two large and apparently unrelated outbreaks. One is centered in Orthodox Jewish communities in New York City and its suburbs; that outbreak began in October and recently spread to Orthodox communities in Michigan.

The other outbreak began in Washington State…

The New York outbreak was set off by Americans who had visited Israel, where cases have been spreading in Orthodox communities since early last year. City officials have taken extraordinary measures to crack down on resistance to immunization.

Mayor Bill DeBlasio declared a state of emergency and threatened residents of four Brooklyn ZIP codes with $1,000 fines if they refused to vaccinate.

Twelve summonses have been issued so far, the city health department said; people who do not answer them can be fined $2,000. City officials closed a yeshiva preschool for violating vaccination orders.

Rockland County, N.Y., the center of another outbreak, initially barred unvaccinated children from all indoor public places, including schools, malls, supermarkets, restaurants and houses of worship.

After a court blocked that order, the county instead barred from public spaces anyone who had measles symptoms or who had recently been exposed to the disease, threatening them with fines of up to $2,000 a day.”  (A)

“More than 1,000 students and staff members at two Los Angeles universities were quarantined on campus or sent home this week in one of the most sweeping efforts yet by public health authorities to contain the spread of measles in the U.S., where cases have reached a 25-year high.

By Friday afternoon, two days after Los Angeles County ordered the precautions, about 325 of those affected had been cleared to return after proving their immunity to the disease, through either medical records or tests, health officials said.

The action at the University of University of California, Los Angeles, and California State University, Los Angeles — which together have more than 65,000 students — reflected the seriousness with which public health officials are taking the nation’s outbreak…

“This is a legally binding order,” the county’s public health director, Dr. Barbara Ferrer, told reporters.”

Anyone who violates it could be prosecuted, she said, but added that it appears everyone is cooperating so far. She didn’t describe what penalties those who don’t could face.  (B)

Measles is making a comeback in 2019.

“Since January of this year, 22 states have experienced a total of 695 cases of measles, an infectious disease that was supposed to be eradicated almost two decades ago following an outbreak of more than 30,000 cases and a push to get everyone vaccinated — twice…

“This year is the worst since 2000.” said Dr. Sean O’Leary, a pediatric infectious diseases specialist working with the American Academy of Pediatrics. “There are more pockets now of parents who have chosen not to immunize their kids. And when someone with measles comes into that community, it spreads.”” (C)

CDC Measles Tracking by State

https://www.cdc.gov/measles/cases-outbreaks.html

HISTORY (D)

Pre-vaccine Era

In the 9th century, a Persian doctor published one of the first written accounts of measles disease.

Francis Home, a Scottish physician, demonstrated in 1757 that measles is caused by an infectious agent in the blood of patients.

In 1912, measles became a nationally notifiable disease in the United States, requiring U.S. healthcare providers and laboratories to report all diagnosed cases. In the first decade of reporting, an average of 6,000 measles-related deaths were reported each year.

In the decade before 1963 when a vaccine became available, nearly all children got measles by the time they were 15 years of age. It is estimated 3 to 4 million people in the United States were infected each year. Also each year, among reported cases, an estimated 400 to 500 people died, 48,000 were hospitalized, and 1,000 suffered encephalitis (swelling of the brain) from measles.

Vaccine Development

In 1954, John F. Enders and Dr. Thomas C. Peebles collected blood samples from several ill students during a measles outbreak in Boston, Massachusetts. They wanted to isolate the measles virus in the student’s blood and create a measles vaccine. They succeeded in isolating measles in 13-year-old David Edmonston’s blood.

In 1963, John Enders and colleagues transformed their Edmonston-B strain of measles virus into a vaccine and licensed it in the United States. In 1968, an improved and even weaker measles vaccine, developed by Maurice Hilleman and colleagues, began to be distributed. This vaccine, called the Edmonston-Enders (formerly “Moraten”) strain has been the only measles vaccine used in the United States since 1968. Measles vaccine is usually combined with mumps and rubella (MMR), or combined with mumps, rubella and varicella (MMRV). Learn more about measles vaccine.

Measles Elimination

In 1978, CDC set a goal to eliminate measles from the United States by 1982. Although this goal was not met, widespread use of measles vaccine drastically reduced the disease rates. By 1981, the number of reported measles cases was 80% less compared with the previous year. However, a 1989 measles outbreaks among vaccinated school-aged children prompted the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) to recommend a second dose of MMR vaccine for all children. Following widespread implementation of this recommendation and improvements in first-dose MMR vaccine coverage, reported measles cases declined even more.

Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the United States in 2000. This was thanks to a highly effective vaccination program in the United States, as well as better measles control in the Americas region.

Photos reveal what it looks like to get the measles when there are no vaccines, by Hilary Brueck,

https://www.businessinsider.com/what-measles-looks-like-2019-4

Complications (E)

Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.

Even in previously healthy children, measles can cause serious illness requiring hospitalization.

One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.

One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.

Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.

People at High Risk for Complications

People at high risk for severe illness and complications from measles include:

Infants and children aged <5 years

Adults aged >20 years

Pregnant women

People with compromised immune systems, such as from leukemia and HIV infection..

Healthcare personnel

Healthcare personnel should have documented evidence of immunity against measles, according to the recommendations of the Advisory Committee on Immunization Practices

“In asserting the constitutionality of vaccination mandates and coercive public health orders, public health lawyers generally look back to the Supreme Court’s 1905 case of Jacobson v. Massachusetts. In that case, the Supreme Court upheld a law mandating smallpox vaccination stating, “Upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”

The Jacobson case is still the starting point for any discussion of the constitutionality of public health emergency powers, and courts in the modern era have continued to cite it in upholding state vaccine mandates…

The reason Jacobson endures, while other cases and public health practices from its era have been cast aside, is that its central message — “there are manifold restraints to which every person is necessarily subject for the common good” — remains as relevant today as it was in 1905. Public health still requires some limitations on individual freedom. Still, exactly what limitations Jacobson countenances, and how its reasoning should be applied in our own, very different era, are deeply contested and will assuredly be debated as the New York litigation continues.

Even if the courts conclude, as they might, that Jacobson supports the Rockland County and New York City orders, that doesn’t mean Jacobson provides the most effective model for stopping contemporary outbreaks. After all, in what other areas do public officials rely upon approaches that were used in 1905?..

No compromise is likely to be perfect, or fully effective. Many will likely fail. But the return of measles suggests that our old, tried-and-true methods of mandates and emergency orders don’t seem to be solving the problem of vaccine resistance. New tools are needed before more dangerous outbreaks of even more lethal diseases occur. “ (F)

‘Ninety-nine times our legislative bodies have passed such legislation. And that’s gone to the governors that have represented the entire political spectrum in the United States that have signed that legislation all for the benefit of our children and healthier communities. Now think about that — 99 times. That’s the epitome of democracy. Nothing that I can think of has been so profound in affecting the health of children, because those laws have obliged most children to be vaccinated…

But measles has been reintroduced into the Western Hemisphere in two countries; in the United States and Venezuela. What? Two different reasons. In the United States, it’s because some parents, whether for cultural reasons, misunderstood religious reasons, or kind of libertarian reasons, have withheld many children from vaccination creating pockets and communities of susceptible children…

I think every child should be vaccinated and I will now make a bold statement. I think there ought to be valid — valid — medical reasons for exclusion from vaccination. I’m not a friend of either personal belief or religious exemptions. We have three states that have such tight laws now: West Virginia, Mississippi, and California. I think they’re leaders and the rest of us should follow. I wouldn’t want any child to suffer measles or its complications.

I’ll remind you of one thing before I come to a close. Before we had [a] measles vaccine, 400 to 500 children died in the United States annually because of measles and its complications. That number now is zero.”… (G)

“Measles, a virus that invades the nose and throat, causing fever, cough and phlegm, is one of the most contagious pathogens on the planet. Before 1963, it infected some four million people every year in the United States alone. Nearly 50,000 of them would land in the hospital with complications like severe diarrhea, pneumonia and brain inflammation that sometimes resulted in lifelong disability. Of the 500 or so patients who died from these complications each year, most were children younger than 5.

Until recently, those numbers were a matter of history. The measles vaccine, which was introduced to the United States in 1963, drove the annual case count from four million to zero inside of four decades. Measles was officially eradicated in America in 2000 and was largely wiped from our collective memory soon after.

But in the shadow of that memory lapse, a different virus has spread: anti-vaccine propaganda and vaccine misinformation. Both have persuaded a small but growing number of parents that vaccines designed to inoculate against infectious diseases pose a greater health risk than the diseases themselves. As a result, these parents are skipping crucial shots for their children. And as the number of unvaccinated children grows, some vaccine-preventable diseases are making a comeback.

The Centers for Disease Control and Prevention has logged at least six measles outbreaks so far this year, across five states, involving more than 100 patients. In recent weeks, as those numbers have ticked upward, both houses of Congress have held hearings to discuss the issue, while more states have considered limiting vaccine exemptions for school-age children and several prominent social media platforms have pledged to block anti-vaccine propaganda and vaccine misinformation from their sites…

But the new rash of outbreaks has made clear that even small pockets of vaccine hesitancy and refusal can have grave consequences. And health officials say that if left unchecked, this outbreak crisis will only worsen…” (H)

 “The outbreak of measles in the U.S. and around the world is due largely to inadequate vaccination rates in some communities, not illegal immigration, as one popular meme on Facebook claims.

The meme shows a picture of a baby who appears to be infected with measles and says: “Thanks to a highly effective vaccination program the Measles virus was eliminated from the U.S. in 2000. Thanks to the immigrants who illegally cross the U.S. Mexican border, and the Democrats who refuse to stop them, the Measles virus has been declared a public health emergency in 2019.”

The first part of that claim is correct. Measles was eliminated in the United States in 2000 and it was eliminated across both North and South America in 2016…

The second part of the claim, however, is incorrect.

The virus has been brought into the U.S. by people who have traveled to places where there is an outbreak or where the disease is still common, such as parts of Europe, Africa, Asia, and the Pacific, according to the Centers for Disease Control and Prevention. From those travelers, the disease can then spread in U.S. communities that have unvaccinated people, according to the CDC.

For example, the New York City health department declared a public health emergency on April 9. That measles outbreak, which started in 2018 and spread in the Orthodox Jewish community, was brought on by travelers who had been in Israel, where a large outbreak is occurring, according to the Pan American Health Organization”… (I)

“The Washington state Senate narrowly passed a measure late Wednesday that would make it harder for parents to opt out of vaccinating their children against measles in response to the state’s worst outbreak in more than two decades.

The bill, which would eliminate personal or philosophical exemptions from the measles, mumps and rubella (MMR) vaccine, is a victory for public health advocates who had not expected it to make it to the floor…

The bill is expected to pass the House, where a nearly identical measure was approved last month, and be signed into law by Gov. Jay Inslee (D). It would be the first time in four years a state has removed personal exemptions in the face of growing anti-vaccine sentiment. California and Vermont removed personal exemptions in 2015. Other states have tightened vaccination requirements but have not removed exemptions…

The stricter rule would apply only to immunizations for measles, mumps and rubella. Parents would still be able to cite personal or philosophical exemptions to avoid other required school vaccinations for their children. Religious and medical exemptions will still be allowed for all vaccinations, including MMR.

Advocates and lawmakers were able to overcome strong lobbying by anti-vaccine groups, which are among the most vocal and organized in the country. Those groups mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, turned out for public hearings and proposed poison-pill amendments, intended to weaken a bill or ruin its chances of passing…

Campaigns to toughen state requirements in Iowa, Colorado, Maine and Oregon also face strong opposition. Washington is one of 17 states that allow exemptions from required immunizations for personal or philosophical beliefs.”  (J)

California would give state public health officials instead of local doctors the power to decide which children can skip vaccinations before attending school under legislation proposed Tuesday to counter what advocates call bogus exemptions.

The measure would also let state and county health officials revoke medical exemptions granted by doctors if they are found to be fraudulent or contradict federal immunization standards. The proposal comes amid measles outbreaks in New York, Washington and elsewhere that are prompting states including Maine and Washington to consider ending non-medical exemptions.

California eliminated all non-medical immunization exemptions in 2016, as have Mississippi and West Virginia. The lawmakers want California to now follow West Virginia’s lead in having public health officials rather than doctors decide who qualifies for medical exemptions. Doctors would send the state health department the reason they are recommending the exemption and would have to certify that they examined the patient….(K)

“In a statement this week, U.S. Secretary of Health and Human Services Alex Azar reiterated a tactic that has proven ineffective at reaching skeptical populations in recent years: telling them what to do. “Vaccines are a safe, highly effective public-health solution that can prevent this disease,” he said. “The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken.”…

Research suggests that the reason informed people fall into conspiracy-theory mind-sets often has less to do with a lack of information than with social and emotional alignment. Facts are necessary, but not at all sufficient. Websites and YouTube videos where a federal employee in a suit states various statistics are unlikely to be effective against targeted disinformation campaigns that only need to plant the seed of doubt in the mind of people already skeptical of the medical establishment. The work of global inoculation requires first rebuilding a social contract, which means meeting people on the platforms where they now get their information, in the ways they now consume it.” (L)

“It was actually measles outbreaks in the 1960s that inspired a push to have states require children get inoculated before starting kindergarten. By the 1980s, all states had mandatory immunization laws in place. The idea behind these laws was simple: Near-universal vaccinations sustain herd immunity.

Still, there’s a lot of variation across the country when it comes to immunization requirements. Even though all 50 states have legislation requiring vaccines for students entering school, almost every state allows exemptions for people with religious beliefs against immunizations, and 17 states currently grant philosophical exemptions for those opposed to vaccines because of personal or moral beliefs. (The exceptions are Mississippi, California, and West Virginia, which have the strictest vaccine laws in the nation, allowing only medical exemptions.)

In these places, opting out can mean simply listening to a doctor or health official explain the benefits of vaccination or getting a signed statement about your religious beliefs notarized. It’s often harder for parents to sign their kids out of school for the day than to help them avoid vaccines.

In 45 states, even without an exemption, kids can be granted “conditional entrance” to school on the promise that they will be vaccinated, but schools don’t always bother to follow up…

California has made it tougher to opt out of vaccines — with mixed and instructive results

Some states have been moving to crack down on vaccine avoiders — most notably California — and the experience there is instructive for states that might want to close some of their loopholes…

There is indeed evidence from Mississippi and West Virginia that strict vaccine laws can work — but again, interpret it with caution.” (M)

“If the U.S. loses its “measles elimination” status, it will join Venezuela as the only other country in North and South America with this distinction. Measles was declared eliminated across the Americas in 2016, but within a year, an outbreak sparked in Venezuela that has persisted up to the current day.

For most Americans, these outbreaks are a bittersweet wake-up call about the importance of the measles-mumps-rubella (MMR) vaccine. Thanks to the success of vaccination programs, most people are unfamiliar with measles itself — which means they may be unsure about how to approach these outbreaks and protect themselves.” (N)

“And although the majority of people getting the illness now were never vaccinated, the expanding outbreaks have raised new questions about whether some older adults — including many of those born before the mid-1960s — should be revaccinated, along with some younger people uncertain of their immunization status.

According to the Centers for Disease Control and Prevention, people who were vaccinated prior to 1968 with an early version of the vaccine, which was made from an inactivated (killed) virus, “should be revaccinated” with at least one dose of live attenuated measles vaccine.

Today’s recommended vaccine is known as MMR and protects against measles, mumps and rubella.

“This recommendation is intended to protect those who may have received killed measles vaccine, which was available in 1963-1967 and was not effective,” according to this Q & A on measles from the CDC…”  (O)

PART 2. May 6, 2019

“We are getting very close to a tipping point. If (measles) cases continue to escalate, the U.S. could lose its elimination status…”

“ON AN OTHERWISE normal Thursday in November 2018, the doors to the Lowell Community Health Center in Massachusetts opened at 8 a.m., as they always do, and the first of 802 patients who would walk through those doors began trickling in…

This routine — a seemingly banal choreography repeated hundreds of times each day — continued until around 12:50 p.m., when a mother arrived with her two-year-old daughter. The child had measles, and suddenly, this was no longer an ordinary day. For virtually anyone not immune to the virus who crossed paths with the toddler, infection was almost certain, and so all of those places the child had been and the rooms where she may have coughed or sneezed became critical evidentiary artifacts in a crisis that had all the potential to spin quickly out of control.

Indeed, the arrival of mother and child set off a chain of events and triggered longstanding but rarely tested protocols aimed at containing a measles outbreak. It involved hundreds of staff not just at the Lowell Community Health Center, but also the Massachusetts Department of Public Health (DPH), the City of Lowell Health Department, and the local hospital — with thousands of emails and a weeklong flurry of activity that strained the center’s capacities to the limit…

That the center managed to contain the highly-contagious measles virus is a testament to its modernized records system, its staff’s military-style precision, and its location in a resource-rich region. But even here there were occasional missteps, bouts of confusion, and administrative second-guessing and finger-pointing. There were also 179 exposed people with no evidence of vaccination — even though the center tried to reach them — suggesting that the fallout at a less-prepared facility could be disastrous…

ON NOVEMBER 7, the child’s mother called the center for an appointment. She said her daughter had a cough and a rash and some sores in her mouth, and asked if they could come in.

Here, the staffer on the phone made the first crucial mistake. Lowell is an old New England mill town with weathered red-brick buildings interconnected by canals, and as a large suburb of Boston, it is heavily populated these days by immigrants; nearly 40 percent of the center’s patients don’t speak English. Protocol would have dictated that center staff ask the mother about recent travel while she was still on the phone, but that didn’t happen. Had the question been asked, staff would have learned that the mother and child had just returned from a month-long trip to an African country where measles is endemic. Although the toddler had received one shot of the measles, mumps, and rubella (MMR) vaccine at the center when she was one, and a single dose is supposed to be 93 percent effective, it may have been no match for the heavy exposure.

Had the staffer asked, mother and daughter would likely have been directed straight to an isolation room, intended for anyone with a contagious illness, on the center’s ground floor. Instead, they came to the center and disclosed to a medical assistant upon arrival that the child had contracted measles abroad…

At approximately 2 p.m., they gathered in a conference room to strategize and to connect with other officials via conference call. Health care organizations are required to have an emergency plan in place, and the center’s chief information officer, Henry Och — an infantry officer in the National Guard, with stints in Kosovo and Afghanistan — would play the role of incident commander…

 “If this happened in a school and not a health center — who’s responding, and how is it being managed?” Vigroux asked. “I think our community is not ready for that.” (A)

“Incidence of measles in Europe spiked dramatically from 2016-2018 in a handful of countries, led by the Ukraine, researchers found…

The World Health Organization’s (WHO) European Region, which contains countries outside of what is traditionally thought of as Europe, went from a little under 5,300 reported cases of measles in 2016 to nearly 83,000 reported cases of measles in 2018 — a fourteen-fold increase, the authors wrote in the Morbidity and Mortality Weekly Report…

When citing reasons for ongoing measles transmission, the authors pointed to factors that appear to be playing a role in the U.S.’s ongoing measles outbreak — namely “an accumulation of susceptible young children in marginalized communities with suboptimal coverage.” Other reasons included persistent measles virus reservoirs in WHO European Region countries “with limited resources and weak immunization systems.”

The majority of measles cases were from the Ukraine — which was previously cited by CDC researchers as one of the top three countries exporting measles to the U.S. In 2018, there were over 53,000 cases in the Ukraine, comprising two-thirds of all measles cases in this region. Second was Serbia, with around 5,000 cases (6% of the total) followed by France and Israel with about 2,900 cases each (each 4% of the total)…”  (B)

“New Jersey’s growing measles outbreak appears to have roots in Israel, New York City and New York’s Rockland County, according to Garden State officials.

Department of Health Commissioner Dr. Shereef Elnahal said a combination of travelers returning from countries where measles is rampant, and individuals crossing back and forth between neighboring states, is largely responsible for the situation in New Jersey. Fourteen Garden State residents have been diagnosed with the virus this year, in addition to the 33 infections detected last fall. Another case is expected to be confirmed this week.

But with New York City experiencing a more severe outbreak, with at least 420 cases, and another 200-plus diagnosed in nearby Rockland County, the threat of cross-border contamination is significant, Elnahal said. Most of the infections have been found within Orthodox Jewish communities in both states, including Ocean County’s Lakewood.

Since community members often travel back and forth for family visits, work or worship, Elnahal said “the transit between New York and New Jersey is the biggest concern now. And the collaboration with (local and state health officials in New York) has been critical.” International travelers have long been the source of viral infections in the United States, Elnahal said, but with more people refusing the vaccine there is a greater chance that infected voyagers can transmit the disease, which spreads quickly in communities with low immunization rates…

Exemptions are permitted for medical reasons (those with compromised immune systems are at risk) and also for religious reasons, although lawmakers in New Jersey and several other states are looking to eliminate the religious opt-out. Elnahal said all the religious leaders he has encountered, including prominent Jewish officials, have urged their followers to comply with vaccination laws.” (C)

“The country is experiencing the worst year for measles in a quarter century, according to the Centers for Disease Control and Prevention (CDC), with 704 reported cases. And New Jersey is right in the middle of an outbreak…

While it’s unlikely New Jersey would ever see hundreds or thousands of cases at once, the state could see localized epidemics with “pockets of people with low vaccination rates getting many infections,” Dr. David Cennimo, an infectious disease expert at Rutgers New Jersey Medical School, said via text

Cennimo said the state is already seeing a “disruption in medicine because of concern for measles.” Treating a measles patient is often tedious and cumbersome, he said.

“Measles is airborne, so people need to stay in special negative-pressure rooms. … These rooms aren’t plentiful,” Cennimo said in an email. “You cannot have a patient walking into a waiting room with measles without a mask on because they can infect everyone.”

Measles is so contagious that 90% of susceptible people exposed to an infected person will become infected, according to the CDC. If outbreaks continue, experts worry about measles patients walking among the public or in hospitals, potentially spreading the disease to vulnerable populations, like babies who’ve yet to receive the vaccine. Those with weakened immune systems, like cancer patients undergoing treatment, would also be at-risk.

Medical personnel may have to ramp up protocols for dealing with patients reporting vague symptoms like a rash or fever. They may have to meet potentially infected patients in the parking lot with masks, diverting staff from other serious health matters.

“All of this is cumbersome and, if it delays care, potentially dangerous,” Cennimo said. “It is difficult for your average primary care doctor or pediatrician to do all of this in a busy office. The measles rash is not very specific and can be confused with other viral rashes.”

He added, “This can really slow down the flow in an (emergency department).” “ (D)

“If you visited the South Plainfield Sky Zone Trampoline Park at 600 Hadley Road on the afternoon of April 22 or the River 978 Banquet Hall at 978 River Ave. in Lakewood on the night of April 23 you may have been exposed to measles, according to the state Department of Health.

A New Yorker with a confirmed case of the virus visited both locations, according to the DOH. The department is warning anyone who visited Sky Zone from noon to 5 p.m. April 22 or the banquet hall from 6 p.m. April 23 to 1 a.m. April 24 that they may have been exposed.

“Anyone who suspects an exposure is urged to call a health care provider before going to a medical office or emergency department,” the department’s statement read. “Special arrangements can be made for evaluation while also protecting other patients and medical staff from possible infection.”

Anyone who may have contracted the virus in this most recent incident may not develop symptoms until as late as May 14, according to the DOH.

On April 22, the DOH announced that a Middlesex County resident with “a highly suspect case of measles” had visited Rosalita’s Roadside Cantina on Route 9 in Marlboro on April 19. The DOH later issued an update, advising that the possible carrier had also visited a Manalapan LabCorp diagnostic center on April 17 and 19.” (E)

‘The return of measles may be an early warning sign of a resurgences of other vaccine-preventable diseases such as rubella, chickenpox and bacterial meningitis, some experts say…

The use of quarantines and other orders are driven in part by a growing concern that outbreaks of measles and other diseases could get worse, despite the availability of effective vaccines, some health experts said.

“I think there’s a sense of anxiety and even a little panic in the public health community” as officials see high levels of mistrust of government and science from a surprising number of people, said Lawrence Gostin, a Georgetown University public health law expert.

That anxiety has led to what Gostin believes are missteps by officials.

It’s one thing to isolate someone with measles or to quarantine someone who has been exposed, he said. Those people are infection risks, and short-term limitations of where they can go and who they can meet are legally and medically appropriate, Gostin said.

But it’s another thing to take the kind of step Rockland County initially did, in which unvaccinated kids were placed under house arrest — not because they were infection risks, but because their parents weren’t listening to public health officials, he said.

One community had success without taking such measures. Officials in Vancouver, Washington, declared an end Monday to a measles outbreak that began in January but apparently stopped at 71 cases a month ago. It was a much smaller community than New York City or Los Angeles and was tamed by an intense investigation and vaccination campaign that involved 230 health workers tracking down infected people and those they had contact with, at a cost of about $865,000.”  (F)

“California public health officials are warning moviegoers who went to see “Avengers: Endgame” and other films at an Orange County movie theater last Thursday that they may have been exposed to measles by a woman in the audience.

The woman attended a midnight screening of the “Avengers” blockbuster at the AMC Dine-In Fullerton 20 on Thursday from 11 p.m. to 4 a.m, the Orange County Health Care Agency said.

Everyone who was in the building may have been exposed, not just at that particular screening room, the agency said.

The warning also applies to people who went to buildings at 5 Hutton Centre Drive in Santa Ana from last Wednesday through Friday.

The woman, who is in her 20s, reported having recently traveled to a country with widespread measles activity, the agency added.” (G)

“A cruise ship was quarantined Tuesday in Saint Lucia after the island nation’s chief medical officer cited concerns that crew members and passengers possibly infected with measles might spread the highly contagious virus, causing an outbreak…

Quarantines are one of many measures used by public health officials to limit the spread of disease, especially to vulnerable populations, such as pregnant women, unvaccinated children, and those with weak immune systems.

According to the Centers for Disease Control and Prevention, a quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. This is different than isolation in which sick people are identified and separated from people who are not sick.

“Isolation is used to separate ill persons who have a communicable disease from those who are healthy. The most important thing is that a distance is created between the respiratory secretions of the infected person and others. The person on the cruise ship has to stay in their room and not come into contact with others, especially those who are not vaccinated,” said Dr. Mirella Salvatore, a travel medicine and infectious diseases expert at Weill Cornell Medicine and New York-Presbyterian…

Quarantine times vary, but typically last for at least 21 days — the typical the time from the moment of measles exposure to the time when signs and symptoms of the disease disappear — or until public health officials can prove that everyone is immune and safe.” (H)

“The cruise ship that was placed under quarantine by St. Lucia because of a confirmed case of measles onboard is bound for Curaçao. It’s not clear what will happen when the vessel, called the Freewinds, arrives there…

Health authorities in St. Lucia made the decision to quarantine the Freewinds after a female crew member was confirmed to have measles. There was concern that others onboard might have been infected and that measles could spread to the Caribbean island, which has been free of local transmission of the disease since 1990. St. Lucia’s Ministry of Health and Wellness said on Thursday it had provided 100 doses of measles vaccine to people on the ship…

As we reported Thursday, the Church of Scientology says its members rely on the advice and treatment of medical doctors, but several high-profile Scientologists have spoken out against vaccination.

Curaçao’s vaccination rate is 97% in children born since 2007, according to the Pan American Health Organization.” (I)

“Authorities in Curacao on Saturday boarded a ship that arrived in the Dutch Caribbean island under quarantine, to start vaccinating people to prevent a measles outbreak.

Health officials said only those who already have been vaccinated or have previously had measles will be free to leave the 440-foot (134-meter) ship Freewinds, which reportedly belongs to the Church of Scientology.

Curacao epidemiologist Dr. Izzy Gerstenbluth told The Associated Press that a small team is assessing more than 300 people aboard the ship, and that the process might take more than a day.

“We will go on board and do our job,” he said, adding that authorities have an international obligation to avoid spreading the disease. “If we allow that to happen, measles spreads in places where the risk of severe complications is much bigger, especially when we’re talking about poor countries where people have a lower level of resistance.” (J)

“New York City saw its first and only patient with the deadly Ebola virus 4½ years ago. Since then, emergency and health-care workers have been training for the next patient.

To test their preparedness for treating a patient with Ebola or another similar deadly infectious disease, fire, police, city and medical workers ran a drill, acting out the steps, over two days late last week, while nurses and doctors evaluated them.” (K)

“In order to prepare for viral outbreaks occurring in other parts of the world, New York City and State partnered with first responders in New Jersey to conduct an emergency exercise last week to transport a person pretending to be an Ebola patient to NYC Health + Hospitals / Bellevue. Agencies that participated in the drill included the Health Department, NYC Health + Hospitals, the Fire Department of the City of New York, New York State Department of Health, the Robert Wood Johnson University Hospital, and health and law enforcement agencies from New Jersey. The exercise entailed the transfer of a person pretending to be an Ebola patient from Robert Wood Johnson University Hospital in New Jersey to the Regional Ebola and Other Special Pathogen Treatment Center at NYC Health + Hospitals / Bellevue in New York City…

This exercise – the first of its kind between New York City and New Jersey – tested the health care system’s ability to safely move a patient to a clinical setting where Ebola can be most effectively treated. In particular, the exercise assessed the ability of participants to coordinate patient transportation to NYC Health + Hospitals / Bellevue, safely use biocontainment devices and personal protective equipment while caring for the patient, and appropriately decontaminate and dispose of equipment after transportation. Today’s unprecedented exercise involved over 70 staff from participating health care facilities and state and local agencies.”(L)

“Nearly 70 of the city fire department’s emergency medical techs and paramedics are not vaccinated for measles, according to sources…

The FDNY’s Bureau of Health Services went through all the immunization records after the outbreak, and realized that they had a population of unvaccinated members who were vulnerable to the disease.

The obvious danger was that they could contract the illness, officials said. But they could spread it as well.” (M)

“Maine could soon prohibit parents from citing religious or personal beliefs to avoid vaccinating their children, making the U.S. state one of a half dozen cracking down during the nation’s largest measles outbreak in 25 years.

State legislatures in New York, New Jersey, Oregon, Vermont, Minnesota and Iowa are looking at similar bills that would only allow exemptions from vaccinations for medical reasons as determined by the child’s doctor…

Maine has one of the lowest vaccination rates in the country, with 5 percent of kindergartners holding a non-medical exemption from vaccination, compared to a national average of 2 percent, according to CDC data.

The World Health Organization has said at least 95 percent of a community must be immunized against measles to achieve the “herd immunity” needed to protect those unable to get the vaccine such as infants and people with compromised immune systems.

No measles cases have been recorded in largely rural Maine since 2017, but state officials have been worried by outbreaks of whooping cough, another childhood disease that can be prevented by vaccination.” (N)

“The measles vaccines are among the most extensively studied medical products. The safety of both vaccines has been firmly established over many years in some of the largest vaccine studies ever undertaken. Before the vaccines’ approval, clinical data developed through animal studies and human clinical trials were evaluated by FDA scientists and clinicians.

In addition, the FDA pays careful attention in reviewing the quality of raw materials and other ingredients used to make vaccines, the production process, and the procedure for assessing their safety and efficacy. Like many medical products, measles vaccines have known potential side effects, but they are generally mild and short-lived, such as rash and fever.

The bottom line is that there are safe and effective vaccines that provide lasting protection against the measles virus. Both contain live, but weakened versions of the measles virus, which causes your immune system to produce antibodies against the virus without causing you to contract the illness. Should you be exposed to actual measles, those antibodies will protect you against the disease.” (O)

“The U.S. is experiencing the greatest spike in measles cases in 25 years, but Merck, the sole producer of the measles vaccine for the U.S., says it has production in hand…

“In response to the measles outbreak that has occurred this year, Merck has taken steps to increase U.S. supply of our MMR-II vaccine so availability of the vaccine is maintained,” the company said in an emailed statement today. The statement emphasized the safety and effectiveness of the vaccine has been scientifically affirmed over decades of use against the highly contagious and sometimes fatal disease…

Merck Chief Marketing Officer Mike Nally told Reuters in an interview that the company has upped production but that there has not been a big boost in orders in the U.S., even from the Centers for Disease Control and Prevention. The CDC provides vaccines through the government’s Vaccines for Children program…

 “As measles outbreaks have occurred in different parts of the world over the last few decades, we’ve always been able to surge capacity, and we feel confident about our ability to do so in the U.S,” Nally told the news service.” (P)

“In New York, which has seen hundreds of measles cases since last fall, the state’s Department of Health has given doctors the go-ahead to lower the vaccination age to six months in areas with ongoing outbreaks, according to Erin Silk, a spokesperson for the department. New York City Mayor Bill de Blasio has ordered that everyone — including babies as young as six months old — get their measles vaccinations. The measles vaccine is safe and effective, despite the thoroughly debunked myth that vaccines cause autism. An extra measles vaccine at six months is very safe, too, according to Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine. It just isn’t the norm because, under typical, non-outbreak circumstances, the vaccine may not be as effective for babies that young. “However, some babies could still benefit from early immunization during a true measles outbreak,” he says in an email to The Verge.” (Q)

“After a measles outbreak in Brooklyn and Rockland County and amid growing concerns about the anti-vaccine movement, a pair of state legislators are proposing allowing minors to receive vaccinations without permission from their parents.

The bill would allow any child 14 years or older to be vaccinated and given booster shots for a range of diseases including mumps, diphtheria, whooping cough, tetanus, influenza, hepatitis B and measles, which seemed to be the primary reason for alarm after the recent outbreaks.

“We are on the verge of a public health crisis,” said one of the bill’s sponsors, Assemblywoman Patricia Fahy, a Democrat from Albany, citing lower-than-recommended inoculation rates in some communities, spurred by unconfirmed suspicions about vaccines causing autism. “We’ve become complacent over the last couple of decades.”

That sentiment was amplified recently by the World Health Organization, which listed “vaccine hesitancy” as one of the Top 10 global threats. In Rockland County, officials are reporting 145 confirmed cases of measles, with the vast majority of those afflicted aged 18 and under. Of those, four out of five have received no vaccinations for measles, mumps and rubella.. “ (R)

“U.S. doctors are tapping into their electronic medical records to identify unvaccinated patients and potentially infected individuals to help contain the worst U.S. measles outbreak in 25 years.

New York’s NYU Langone Health network of hospitals and medical offices treats patients from both Rockland County and Brooklyn, two epicenters of the outbreak. It has built alerts into its electronic medical records system to notify doctors and nurses that a patient lives in an outbreak area, based on their Zip code.

“It identifies incoming patients who may have been exposed to measles and need to be assessed,” said Dr. Michael Phillips, chief epidemiologist at NYU Langone Health.

Alerts in a patient’s medical record also prompt conversations with their visitors – who may also have been exposed to the virus – about their own health, prior exposure to measles and vaccination history.

Mount Sinai Health System in New York rolled out a similar program last week, said Dr. Bruce Darrow, its chief medical information officer.

Darrow said it was important because although a patient who comes from a measles-affected Zip code may have passed the screening, family members who visit may have been exposed.”

He said the alert system raises awareness for doctors and nurses “to be on lookout not just for our patients, but anybody who comes into the building.” (S)

“At first, the virus moved slowly through Orthodox communities in Jerusalem and Tel Aviv. Then in September, Dr. O’Connor said, a major outbreak in Ukraine supercharged Israel’s modest one — and probably led, indirectly, to outbreaks in Britain and in the United States.

Ukraine is suffering through a measles outbreak that began in 2017. The country has had almost 70,000 cases — more than any other country in recent years…

But the real problem appears to have begun at Rosh Hashana.

Each year on the holiday, tens of thousands of Orthodox men travel to Uman, a Ukrainian city where the grave of Rabbi Nachman of Breslov, founder of one branch of Hasidism, has become a popular pilgrimage site. (The festivities have been called the “Hasidic Burning Man.”)

Last year, Rosh Hashana fell in early September. Later that month, measles cases exploded in Israel, rising to a peak of 949 in October. The cause? Numerous pilgrims came back from Ukraine with the virus, experts believe.

New York’s outbreak began in October; the first patient was a child in the Bensonhurst section of Brooklyn who had visited Israel. At the same time, a measles outbreak began among Orthodox Jews in London.” (T)

“In 2000, the Pan-American Health Organization announced a monumental public health achievement: Widespread vaccination efforts, overseen by the Centers for Disease Control and Prevention, had effectively eliminated measles from the United States.

The disease, which before the vaccination era affected 3 to 4 million people in the U.S. each year, was now isolated to small, contained outbreaks connected to international travel.

This year’s record-setting outbreak threatens that achievement.

Since January, over 700 cases of measles have been reported in 22 states. Most of the affected have never been vaccinated. Sixty people have been hospitalized, and the case numbers continue to climb, although in some regions, like the Pacific Northwest, outbreaks have subsided.

Though the current numbers are dwarfed by the scale of cases in the first half of the 20th century, they’re still meaningful, says Rene Najera, an epidemiologist and editor of the vaccine education website History of Vaccines.

“We are getting very close to a tipping point. If cases continue to escalate, the U.S. could lose its elimination status,” says Najera.

A disease is considered eliminated from a country when it can no longer be contracted within its borders, though cases tied to international travel — like those that have happened since 2000 — can still occur.

Losing elimination status would mark a failure of one of the biggest public health achievements in our history.” (U)

“Why is handwashing so important?

Put simply, your hands are dirty. As they come into contact with various people, animals, foods, and surfaces, they pick up thousands of germs, bacteria, viruses and other assorted nastiness that can make you sick if they enter your body. “We touch our eyes, noses, and mouths with our hands more than we think, and this can allow direct inoculation of germs into our mucous membranes,” explains Janet Haas, PhD, RN, Director of Epidemiology at Lenox Hill Hospital. “We also use our hands to prepare and eat foods, so hands that are not clean can contaminate foods that we and others will eat.” But washing your hands has the power to minimize or even eliminate those risks—for you and those around you. For example, teaching people about handwashing can reduce diarrheal illnesses in immunocompromised people by up to 58 percent, according to the CDC. Another FYI: You should wash your hands immediately after touching these 10 things.

You’re probably washing your hands wrong

Believe it or not, only 5 percent of people wash their hands in a way that actually gets them clean, according to a study in the Journal of Environmental Health. Haas says the trick is to rub soap onto every part of your hands, since the friction is what removes the germs from skin, and to wash for a long enough period of time. “Keep rubbing for 20 seconds, making sure to get soap between fingers and on the backs of hands—and don’t forget the thumbs!” she advises. “Avoid turning off the tap with your clean hands: A towel, a wrist or elbow is preferred to keep your hands clean.” .. (V)

“U.S. health officials are increasingly relying on an informal network of community groups, religious leaders, and local medical practitioners in their efforts to fight the biggest measles outbreak in the nation in more than 25 years. Standard public-health tools are falling short in the face of an aggressive antivaccination campaign, growing exposure to measles in countries such as Israel, and a longstanding distrust of government or other outside sources of information. Grassroots approaches are becoming more important in public health, with infectious-disease outbreaks around the world increasingly erupting in remote or insular communities, conflict zones, and other areas where disease fighters have to grapple with economic, cultural, or security challenges. CDC has formed a work group to seek new ways to counter an increasingly vocal antivaccine movement. Trusted sources within a community’s own networks “can be more effective than we can” in educating people about vaccination, says Nancy Messonnier, an expert on immunization and respiratory diseases at the agency.” (W)

Prequel: Project Management. The hardest part of getting started….is getting started

Preparing “Raw” Contemporaneous Cases  http://doctordidyouwashyourhands.com/2019/03/method-of-preparing-raw-contemporaneous-cases/

To see more cases go to Doctor, Did You Wash Your Hands?™   http://doctordidyouwashyourhands.com/

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ASSIGNMENT: Is it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive — the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.””  (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected—someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases — now the third-highest after New York and Illinois — has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials.

Although the fungus has been known to medical professionals in New Jersey for two or more years, it was not widely known to the public. Its profile was raised by a front-page story in The New York Times on Sunday describing its growing presence in overseas hospitals and, increasingly, in the U.S.

The best defense against spreading the fungus is rigorous handwashing, and disinfecting hospital rooms and equipment that have come into contact with a patient, Kirgan said.

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.”  (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.”  (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts — funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical director of epidemiology at the Orange County Health Care Agency. “We don’t have an infinite amount of time,” he said. “Taking a chance to try to make a difference in CRE’s trajectory now is really important.””  (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.

Art Caplan, a bioethicist at the NYU School of Medicine, said the issue of full disclosure can be tricky, especially when large hospitals that see huge numbers of seriously ill patients are compared with smaller institutions. “If you’re a hospital of last resort, you’re going to see repeat customers with tough infections, many of them drug resistant,” he said.

Still, he thought there was a greater value in promoting transparency. Public awareness about the lives lost to drug resistant infections, he said, could pressure hospitals to change the way they deal with infection control.

“Who’s speaking up for the baby that got the flu from a hospital worker or for the patient who got MRSA from a bedrail?” he asked, referring to a potentially deadly bacterial infection. “The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change.” (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent.

This could not be happening at a worse time. Antibiotic-resistant microbes, known as superbugs, are pinballing around the world, killing hundreds of thousands of people every year. The Times recently reported on Candida auris, a deadly new fungus that has infected hospital patients in Illinois, New Jersey and New York.

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital — or an entire town — who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois — all in the Chicago area — a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities — such as skilled-care nursing homes or long-term acute-care hospitals — and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…”  (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention — the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively — infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible — the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida — the regular ones — are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).

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Project Management. The hardest part of getting started….is getting started

Every major project (worth doing) is unique! But there is no “magic bullet” Project Management template. However, one way of starting any project is by reaching a consensus on “anchor concepts” which can serve to keep the project on track (and can be revised during the project).

Assignment: Your program is up for a CAHME accreditation visit and you are chairing the “preparation” committee. What are the “anchor concepts?

Following are some “anchor concepts” examples for different types of projects:

In July of 2009 the Mayor of Hoboken asked me to initiate a H1N1 “Swine Flu” Task Force. We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor

An umbrella agency allocated money to 18 different Food Distribution programs in three categories – “meals on wheels”, food pantries, congregate meals – $1 million/ year; & separate pots of money for housing stability, and aging in the community. There had been no review of the allocation in ten years, just automatic renewals. There was no “organizational memory” on why this program was initiated.

We started with some agency – Food Distribution Principles:

Agency is committed to providing basic supports to the most vulnerable in the Jewish community.

Food insecurity exists within the Jewish community and the Agency is committed to a programmatic response.

Funded food programs should reflect Best Practices in the field.

Agency is committed to kashrut. (kosher food)   

In order to address the needs of all those who are vulnerable, the relative size of needy groups should be considered in the distribution of funds.

The rationale for continued Agency funding should be clearly articulated if there are similar nearby programs with available capacity.

Agency funded food programs duplicating similar nearby programs should be open to merger opportunities.

Agency should provide kosher food to those who request it. However given the higher cost of kosher food, a facilitating process should connect those who do not require kosher food to other accessible food programs. 

Food programs funded by the Agency should be nutritionally sound, fully compliant with their regulatory agencies, be certified or accredited if there are certification or accreditation programs in place, and be active members of industry associations.

Funded agencies should have and enforce an effective Conflict of Interest policy.

A Health and Social Services Agency reviewed whether it should change accreditation agencies. We started with a set of assumptions:

“Price” should not be the singular criteria to change Accreditation. Neither should staff effort required.

HSSA should be in the main stream of Accreditation with other similar leading HSSAs in the United States – this is not an area to be a pioneer

Evaluation criteria should be developed first and then a number of Accreditation alternatives should be reviewed

Only “Evidenced-Based” options should be considered. “Best Practices” is not sufficient.

If and when the field is narrowed, HSSAs using these Accreditation vehicles should be contacted for feedback

Any change should not in any way compromise the “rebranding” initiative – check with our consultants

Make sure any change does not affect the professional staff’s certification, licensure, and “credibility“

Make sure any change does not affect HSSA’s reimbursement from any source

Be comfortable that any change will be acceptable to key “funders

HSSA was considering new revenue streams, more specifically “for profit” partnerships to support its NFP mission. So we started with Principles for Social Entrepreneurship Projects – HSSA:

Projects must be consistent with (and enhance) the Mission and Vision of HSSA

Our Mission: Guided by the wisdom and values of our tradition of respect for all people, HSSA provides innovative, compassionate and outstanding social services to enhance the independence and well-being of individuals and families throughout all stages of life.

Our Vision: HSSA will be the premier Agency within the area providing for the social services and mental health needs of the greater community with unparalleled professionalism, humanity and respect for all who seek its support.

Projects must not adversely affect the reputation, “brand”, integrity, fund-raising capability or tax-exempt status of HSSA.

To the greatest extent possible HSSA should seek to identify and replicate successful projects at other similar agencies.

Any new SEP should contribute at least $100,000 a year to the Agency’s bottom line, within a 3 year start-up period.

Priority should be given to Joint Ventures where partners provide start-up funding and take the financial risk and the Agency provides its “name”, experience and reputation (and gets a lower but steady long term income stream).

Project development costs must include the cost of staff time on the project.

“Clients first.”

….who among us can escape the lonesome time? When hours are as days. When the past becomes more real than the future. And thoughts of getting old are replaced by the anxiety of feeling old. New generations move in as old friends fade away. That’s the lonesome time. The time more than any other when people need people. When people need to be needed.

Senior Camps was founded in 1969 to provide overnight camping services to children and adults.

There were initially six summer sessions – each two-weeks long, serving more than 1,400 people annually by 1976.

1982 was a very good year for the agency – more than 4900 people within 43 weeks of programming, including the summer programs, holiday programs, children’s camping, and trips to Florida, California and Israel.

The agency was doing well financially in 1987 with $1,850, 000 in assets earning interest.

In late 1980’s, the agency began to run significant yearly deficits in part because of the capital money being put back into facilities.

In 1991, the property tax was reinstated on both camps at an annual cost of $66,000.

By 1993 the surplus dropped to $30,000.

Time for a new strategic plan…..

Possible Review Questions for Strategic Planning Committee –  May 6, 2010

1.   Review evolution of Mission Statement over time.

a) Does it need any reconsideration in light of the current “sustainability” challenge?

b) What are Camp’s core values?

c) What is our vision for the future?

d) What defines camp? As a Vacation Center?

e) Does Camp actually offer (as the byline says), to energize mind, body and soul?

f) Who is the actual Camp “customer”? Why do they come?

g) Does Camp have a loyal customer base?

h) What describes a camping experience? A vacation experience?

2.   Profile the competition – location, program, amenities, Jewish or secular, cost, “sizzle” etc – any  easy “copycatting we can do”?

a) What are essential facility upgrades to compete?

b) What are essential programs that we should look to add to stay competitive? More active?

c) Can we play-up our spa concept/health and wellness?

3.   What unique groups should be targeted? Jewish? Secular? Special Needs? Special Interests?  How can we expand our marketing efforts with limited resources and staff time?

4. How do we find more groups to partner with in order to sell our product wholesale?

5.  How can we expand off-season use?

6.  How many weeks of Senior Camping are necessary for Camp to still be Camp?

a) Should we look at offering shorter/less defined stays – i.e. more hotel like?

b) How do we become attractive to the Baby Boomers?

7.  What are the impediments to successful Camp fundraising?

8.  Are there grant-writing opportunities for tuition subsidies and/ or capital funds?

9. What’s in a name? Does Camps name work? no!

10. How do we define ourselves in terms of who we serve – i.e. Orthodox, Conservative, Reform, non-Jews, etc.? How do we successfully meet the needs of all of these communities?

11. Can we/should we expand our programming into the Orthodox community?

12.  Is there sufficient diversity on the Board to address the current challenges?

13.  Is Camp being actively marketed to other affiliated seniors agencies?

14. Can the “Jewish” Internet be used to market Camp?

15. How will we measure progress and success (metrics)? 

16. Should we consider running other travel programs?

17.  Are there any Bylaw changes needed (e.g., committee structure, attendance requirements, term limits)?

18.  Should there be a special “free” weekend for various JCC execs, other Jewish agency execs, Rabbis who can send groups – so they can experience Camp?

Strategic Initiatives –  June 2010

1)  Mine affiliated agencies for “wholesale” opportunities

2)  Reach further into the Russian speaking community, both for additional clients and for possible funding streams or grants for scholarships 

3)  Identify possible alliances within the Orthodox communities for both senior groups through the Young Israel Synagogues and for programs to serve younger adults and families

4)  Contact Aspergers, Autism and other special needs organizations to test Camp’s special needs potential

5)  Develop marketing plan for reaching families who might hold family summer-camp sessions at Camp, such as reunion websites and Grandparents.com, and email to USA-Federation email list

6)   Explore joint ventures with non-northeast synagogues, Ys and other institutions that might plan NE Jewish heritage tour with a week at Camp

7)   Research Grant opportunities from Jewish family foundations

8)   Develop donor list for annual donor funding

9)    Develop a marketing plan using existing “best” Jewish web-sites and newsletters, including separate web pages for each Strategic Initiative adopted

10)   Presentations to Executive Director groups, e.g., Jewish Family Services,  ED groups in New Jersey and New York

11)   Identify changes made by successful senior camps

12)   Is it time to change the name of Camp? 

13)   Board Self-evaluation

14)   Recruit graduate program interns in various fields to assist with the “leg work” and planning

“The Strategy” – Three Camps

Camp will be reorganized as 3 separate camp structures

Vacation Center – Our current program for senior adults

Camp for Adults with Disabilities

Retreat Center – More structure and outreach for our already established retreat and rental program.

In April 1991, Hudson Cradle was started to help alleviate the boarder baby crisis. Boarder babies are infants healthy enough to be discharged from the hospital, but do not have a safe place to call home. Hudson Cradle welcomed our first infant resident in March 1992. Hudson Cradle provides care to approximately 42 babies each year. Hudson Cradle is licensed as a Children’s Group Home

2007 Issues

Senior members on the Board of Trustees too long

New Board members join and then leave quickly

Need a Board/ management,  transition/ succession plan

No Strategic Plan

1.   Mission: Is the current Mission Statement still timely and appropriate?

2.   JCMC Affiliation: Is the current arrangement with JCMC still appropriate and working effectively?

3.   Clinical Services: Does HC provide an appropriate and Evidenced Based scope of clinical service to the babies? Are formal affiliation agreements in place for each of these clinical services if not available on-site?

4.   Outcomes: Is it agreed we need to better track outcomes while the babies are at HC Cradle and after they leave?

5.   Program: Should HC expand its program scope beyond residential care? If so are there gaps in care in Hudson County that HC might consider providing?

6.   Cribs: do we have data to demonstrate a real need for more cribs?

7.   Space: how much additional space is needed on-site for the current mission/ program?

8.   Facilities: what immediate facilities improvements are needed regardless of mission/program, e.g., maintenance, life safely etc?

9.   Disaster Plan: Is it agreed HC needs Contingency Plans if the building needs to be evacuated?

10. Contingency Plan: Is it agreed that HC needs a “baby transfer” plan if HC suddenly runs out of money?

11. Jersey City Medical Center/ Greenville: what, if any, are the implications of the closure (or changes) to Greenville and the cutbacks in pediatrics at JCMC?

12. Marketing Plan: why does HC need a Marketing Plan? and/or

13. Development Plan: How can HC’s successful Development efforts be expanded to include the local (Waterfront?) corporate sector?

HUDSON CRADLE – ’08 Strategic Plan (11/29/07)

A. Mission Statement

Hudson Cradle is a Group Home providing full, nurturing care to homeless infants with special health and developmental needs (“boarder babies”). In addition, Hudson Cradle provides counseling, education, and support services to birth or foster parents to prepare them to live as a family. Hudson Cradle also provides outreach and educational services to the community.

B. Strategic Principles

1.  Does the New Jersey Department of Children and Families consider HC an essential Agency “waivered” under the Court order? If so, will DCF agree to give HC 18 months’ notice of future discontinuation of referrals/ admissions? And, will DFC give HC an enhanced reimbursement rate to support the enriched nurse staffing and additional hospital visits necessary to care for the sicker infants being referred?

2.  HC will develop and implement an Evidenced Based Outcomes Dashboard for current and future services.

3.  HC should expand its Mission to include a range of non-residential community services to infants-at-risk. What services should be considered?

4. While continuing residential services, and adding community services, HC should consider becoming an Umbrella Organization for mission compatible small not-for-profits in Hudson County.

5.  The effectiveness of the current contract with Jersey City Medical Center should be monitored as the Medical Center continues it’s restructuring.

6.  Contingency plans should be developed given the announced closing of Greenville Hospital.

C. Facilities

1.  Consideration of moving to a new facility and/ or expanding the number of cribs is deferred.

2.  Review life-safety compliance, immediate repair requirements and space needs for current programs; and then develop a facilities improvement/ expansion plan for the current HC site.

D. Disaster Management

1.  Prepare and stock an “Emergency Medical Kit”.

2.  Create a “pick up and go” medical information file for each infant in residence, and personnel file for each staff member.

3. Design, implement and monitor compliance of a flu prevention protocol (e.g., babies, staff, Board members, visitors, volunteers))

4.  Develop emergency plans for various possible major incidents: chemical, natural, terrorist, bioterrorist, radiological.

5.  Prepare criteria and plans for “Shelter in Place” and various evacuation options.

6.  At least quarterly prepare copy computerized financial data for off-site storage; also scan, for off-site storage, critical documents such as tax-exempt letters, group home license etc.

E. Development/ Marketing

1. Complete historical profile of HC fund-raising accomplishments (as well as previous donors who no longer contribute).

2. Set goal for fund-raising share of HC annual budget.

3. Establish permanent Development Committee in the By-Laws, then

4. Prepare and Annual Development Plan.

5. Prepare job description for a HC Development position including rationale for its being full time or part (and how it will be funded).

F. Board of Trustees

1. The Board should adopt a “Statement of Board Member Responsibilities.”

2. The Nominating Committee should prepare matrix of expertise and term limit dates of current Board members (and additional expertise the Board needs), then,

3. Recruit new qualified potential candidates for Board membership until the matrix is filled.

4. The Chairman and the CEO should develop an Orientation program for new Board members.

5 The Executive Committee should prepare templates for Annual Board Evaluation and individual Board member self-evaluation.

6. At least once a year the Board should discuss a Board Leadership Succession Plan.

G. CEO

1. The Board should approve a current CEO job description (including educational, clinical and experience requirements for any future CEO).

2.  A format for the CEO’s Annual Evaluation should be prepared by the Chairman and approved by the Board.

3.  At least once a year the Board should review a CEO succession plan.

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“President Donald Trump declared that the GOP will now be the “party of health care…”

On March 26, 2017 I posted an obituary on REPEAL & REPLACE after  House Speaker Paul Ryan said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…” (WRECK & REJOICE)

During the ten months between REPEAL & REPLACE and WRECK & REJOICE I posted over seventy updates. You can find links to this chronology further down on this post.

Now there is an opportunity to track four ongoing and competing health care strategies.

  • Medicare for All
  • Court challenges of the Affordable Care Act
  • The new Democrats plan
  • The next Republican plan


__________

What was once seen as a long-shot pitch from Vermont independent Sen. Bernie Sanders during his 2016 presidential campaign is now a proposal that at least four of his Senate colleagues also vying for the party’s 2020 nomination supported during the last Congress. The issue is driving the national political health care debate…

Democrats are already contending with industry groups hoping to shift the focus back to strengthening the current system. Most drug companies, hospitals and insurers oppose Medicare for All, which undoubtedly complicates progressives’ efforts. The party’s left wing is pushing a bold, pricey plan carrying political risks that make Democratic leaders shudder. Despite all the inevitable political hurdles, getting a single-payer law enacted may look easy compared to implementing it…

A single-payer health care plan would significantly change every sector of the health care industry. Hospitals and doctors would need to adjust to a new payment system, the insurance industry would shrink to a fraction of its size, and the government would bring drug companies to the negotiating table to determine prices.

The 2010 health care law left in place most of the existing health care infrastructure in the U.S. Still, experts warn that the lessons from that more incremental transition show how dramatic it would be to shift to a single-payer system.

Supporters aren’t intimidated by the seismic nature of the change. The hope is not just to ensure that everyone has coverage, but also to take on health care companies seeking to maximize their profits, said Adam Green, a co-founder of the Progressive Change Campaign Committee, a political action committee that supports liberal candidates.

“Medicare for All boils down to two things,” Green said. “One is universal coverage. The other is corporate accountability.” (A)

“Here’s where the Democratic candidates stand on Medicare for All:

Sen. Elizabeth Warren (Mass.)

Warren co-sponsored Sanders’s Medicare for All proposal in 2017. But she has said that the broader goal is “affordable health care for every American,” and that there are “different ways” to achieve that objective.

She has previously backed legislation that would allow people to buy into a Medicaid-based public option on state insurance markets.

Sen. Cory Booker (N.J.)

Booker co-sponsored Sanders’s Medicare for All legislation. But he has also rejected that private health insurance be eliminated under such a health care system and has also expressed support for a more incremental approach in which Medicare eligibility is expanded.

Booker has also signed on to legislation that would lower the Medicare eligibility age to 50, as well as a proposal to allow people to buy into a Medicaid option through state insurance marketplaces.

Sen. Kamala Harris (Calif.)

Harris is among a handful of 2020 Democrats who signed on to Sanders’s Medicare for All bill and has said that she would support eliminating private health insurance altogether.

Harris has also co-sponsored proposals that would lower the age of Medicare eligibility to 50 and create a Medicaid option on state insurance markets that people currently ineligible for the program could buy into.

Sen. Bernie Sanders (I-Vt.)

Sanders has long been the most vocal advocate in the Senate for a Medicare for All system and helped popularize the concept during his insurgent bid for the White House in 2016.

He said in an interview on MSNBC on Tuesday night that he would not support any Democratic legislation on health care other than his own Medicare for All proposal. Sanders also reiterated his past assertion that lawmakers should “get rid of” private insurance under such a plan.

Sen. Kirsten Gillibrand (N.Y.)

Gillibrand supports a Medicare for All proposal and co-sponsored Sanders’s 2017 legislation seeking to implement such a plan.

She’s also signed on to measures lowering the age of eligibility for Medicare to 50 and creating a public health care option through Medicaid on individual state insurance marketplaces.

Former Rep. Beto O’Rourke (Texas)

O’Rourke has said he backs “universal health care.” But unlike some of his more progressive challengers, he’s thrown his support behind a different kind of proposal, dubbed Medicare for America, that would allow Americans to join a public Medicare-based plan, while preserving the option to remain on employer-based insurance.

“It responds to the fact that so many Americans have said, ‘I like my employer-based insurance. I want to keep it. I like the network I’m in. I like the doctor that I see,’ ” O’Rourke told The Texas Tribune earlier this month.

Sen. Amy Klobuchar (Minn.)

The Minnesota senator has refused to explicitly support Medicare for All, offering up a more incremental approach to health care reform that would involve creating a public, Medicaid-like option.

On Medicare for All, Klobuchar has said that it is “something we can look to for the future,” but that she wants “action now” — a nod to the likely challenges such a sweeping proposal would face.

(Also: Washington Gov. Jay Inslee; Former Colorado Gov. John Hickenlooper; Rep. Tulsi Gabbard (Hawaii);South Bend, Ind., Mayor Pete Buttigieg; Former San Antonio Mayor Julián Castro; Andrew Yang; Marianne Williamson; Former Rep. John Delaney (Md.) (B)

“CMS Administrator Seema Verma wrote in an op-ed for The Wall Street Journal that “Medicare for All” proposals would harm seniors’ access to care by bringing all Americans into a system created to support just older adults…

“The monetary cost of Medicare for All is surpassed by its moral cost,” she writes. “The plan would strip coverage from more than 180 million Americans and force them into government insurance. It will resemble the Veterans Administration, which has been plagued by unreasonable wait times, poor customer service, provider shortages and little accountability in the administration of care.”” (C)

“The Trump administration is siding with Obamacare opponents who argue that it is unconstitutional and should be scrapped entirely, initiating a new, more aggressive assault on the health care law that will assure the issue will be squarely at the forefront of the 2020 presidential campaign.

The Justice Department shifted its stance, after arguing last year that some parts of the 2010 law — but not all of it — should be struck down in a case brought by the state of Texas. A federal district judge voided the law in a December ruling that is now under appeal.

In a filing late Monday night, the Justice Department said that President Barack Obama’s signature legislative achievement should be wiped out.

“The Department of Justice has determined that the district court’s comprehensive opinion came to the correct conclusion and will support it on appeal,” DOJ spokeswoman Kerri Kupec said in a statement.

The filing draws renewed attention to Trump’s and the Republican Party’s stance that Obamacare, formally known as the Affordable Care Act, should be eliminated. That would include subsidies for coverage and rules popular with voters such as preventing insurers from discriminating against those with pre-existing conditions, limits on coverage and coverage for preventative care.” (D)

“The Affordable Care Act was already in peril after a federal judge in Texas invalidated the entire law late last year. But the stakes ramped up again this week, when President Trump’s Justice Department announced it had changed its position and agreed with the judge that the entire law, not just three pieces of it, should be scrapped.

A coalition of states is appealing the ruling. If it is upheld, tens of millions more people would be affected than those who already rely on the nine-year-old law for health insurance. Also known as Obamacare, the law touches the lives of most Americans, from nursing mothers to people eating at chain restaurants.

Here are some potential consequences, based on estimates by various groups.

Of the 23 million people who either buy health insurance through the marketplaces set up by the law (11.4 million) or receive coverage through the expansion of Medicaid (12 million), about 21 million are most at risk if Obamacare is struck down. That includes 9.2 million who receive federal subsidies.

On average, the subsidies covered $525 of a $612 monthly premium for customers in the 39 states that use the federal marketplace, HealthCare.gov, according to a new report from the Department of Health and Human Services. If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.

States could not possibly replace the full amount of federal subsidies with state funds.

Medicaid, the government insurance program for the poor that is jointly funded by the federal government and the states, has been the workhorse of Obamacare. If the health law were struck down, more than 12 million low-income adults who have gained Medicaid coverage through the law’s expansion of the program could lose it.

In all, according to the Urban Institute, enrollment in the program would drop by more than 15 million, including roughly three million children who got Medicaid or the Children’s Health Insurance Program when their parents signed up for coverage…

As many as 133 million Americans — roughly half the population under the age of 65 — have pre-existing medical conditions that could disqualify them from buying a health insurance policy or cause them to pay significantly higher premiums if the health law were overturned, according to a government analysis done in 2017. An existing medical condition includes such common ailments as high blood pressure or asthma, any of which could require someone buying insurance on their own to pay much more for a policy, if they could get one at all…

The 156 million Americans who get coverage through an employer, as well as the roughly 15 million enrolled in Obamacare and other plans in the individual insurance market, are protected from caps that insurers and employers used to limit how much they had to pay out in coverage each year or over a lifetime. Before the A.C.A., people with conditions like cancer or hemophilia that were very expensive to treat often faced enormous out-of-pocket costs once their medical bills reached these caps.

While not all health coverage was capped, most companies had some sort of limit in place in 2009. A 2017 Brookings analysis estimated that 109 million people would face lifetime limits on their coverage without the health law, with some companies saying they would cover no more than $1 million in medical bills per employee. The vast majority of people never hit those limits, but some who did were forced into bankruptcy or went without treatment…” (E)

““President Donald Trump declared that the GOP will now be the “party of health care.” The problem? His party doesn’t have a health care plan. Congressional Republicans, who failed to repeal and replace Obamacare when they controlled both chambers, were completely blindsided this week by the Trump administration’s surprising decision to back a court ruling that would throw out the entire Affordable Care Act, including the popular protections for people with pre-existing conditions.

The move baffled many in the GOP, who believe the issue cost them the House in the last election. And Axios first reported that House Minority Leader Kevin McCarthy (R-Calif.), a Trump ally, even voiced his concerns over the administration’s decision directly with the president. Republicans from across the spectrum would prefer to focus on more narrow health care issues that are an easier lift, like lowering prescription drug prices.” (F)

“House Democrats are rolling out a plan to strengthen the Affordable Care Act that would expand federal insurance subsidies and reverse the Trump administration’s attacks on the health care law — but avoids the party’s internal fight about more ambitious proposals to extend health coverage…

The Democratic bill is a smorgasbord of provisions to expand health care and undo the Trump administration’s regulatory actions to weaken the ACA:

It expands the tax credits available under the law, both reducing costs for lower-income families and expanding eligibility so middle-class Americans can receive federal assistance.

It creates a national reinsurance program to offset high medical bills for insurers and thereby keep premium increases in check.

It rolls back Trump actions expanding skimpier health insurance plans, giving states the freedom to undermine the law’s benefits requirements, and cutting enrollment outreach funding…

The rest of the bill is a string of more technical provisions: creating a national reinsurance program, fixing the so-called “family glitch” that barred some families from accessing tax subsidies, and, importantly, reversing the Trump administration’s regulatory agenda. The Democratic bill rolls back or otherwise curtails Trump’s expansion of short-term insurance plans not required to meet the ACA’s protections for preexisting conditions. It also requires the administration to spend federal money on enrollment outreach, after Trump officials cut that budget dramatically over the past two years…

Notably missing from the Democratic bill is a public option or Medicare buy-in, the introduction of a government health care plan to compete with the private insurance offerings of the ACA’s marketplaces…

House Speaker Nancy Pelosi has sounded skeptical notes about single-payer and urged Democrats to focus on strengthening Obamacare, their winning message in the midterms, so this new bill doesn’t come as a surprise. Leadership is taking a more deliberate approach to their party’s more ambitious health care ideas, where there is not yet a consensus within the ideologically diverse Democratic majority.” (G)

““Mitch McConnell has no intention of leading President Donald Trump’s campaign to transform the GOP into the “party of health care.”

“I look forward to seeing what the president is proposing and what he can work out with the speaker,” McConnell said in a brief interview Thursday, adding, “I am focusing on stopping the ‘Democrats’ Medicare for none’ scheme.”

The Senate majority leader spent untold weeks and months on the party’s health care quagmire in 2017, when the GOP controlled both the House and the Senate and still failed to repeal Obamacare. The episode caused endless headaches for Republicans as their replacement plan fell apart first, followed by the so-called “skinny” plan they slapped together at the last minute.

Now in divided government, with the Senate majority up for grabs next year and McConnell himself running for reelection, another divisive debate over health care is the last thing McConnell needs. But that’s exactly where Trump is taking Republicans after his administration endorsed a wholesale obliteration of the law in the courts earlier this week.

So the Kentucky Republican and his members are putting the onus on the president to figure out the next steps.

McConnell’s clear reluctance toward trying to draft a sweeping health care bill in the Senate reflects his political instincts: that it’s better to focus on perceived Democratic weaknesses — the left’s push on “Medicare for All” — than to struggle to unify his own party on a plan almost certain to be rebuffed by Senate Democrats and House Speaker Nancy Pelosi (D-Calif.). “ (H)

“The White House is quietly working on a healthcare policy proposal to replace the Affordable Care Act, according to multiple sources with knowledge of the matter.

While it is not clear how far along the process is, work on a proposal has been going on for months. The effort appears to belie criticism that Trump’s decision to restart the debate on healthcare, an issue Democrats used to their advantage in the 2018 midterms, was an error committed without forethought.

“The White House, mainly through the National Economic Council, has been engaged on thinking about health care reform for a while now, and they have been engaged with a group of center-right health policy groups to talk about various proposals and ideas,” a conservative health policy analyst told the Washington Examiner.

The analyst said the administration has been “having conversations” on healthcare policy and has reached out to numerous think tanks, including the Heritage Foundation, the Mercatus Center, and the Hoover Institute…

Policy leaders at several conservative think tanks confirmed to the Examiner that a healthcare plan is indeed the works. They said a proposal would take concepts from the Graham-Cassidy bill, by Sen. Lindsey Graham, R-S.C. and Sen. Bill Cassidy, R-La., and the Health Care Choices proposal, which was signed by many conservative policy leaders, including the Heritage Foundation and former Sen. Rick Santorum, R-Penn. One analyst said a White House proposal would most likely be brought up in the Senate first.

Heritage Foundation Director of Domestic Policy Studies Marie Fishpaw noted that the president has already included concepts from the Health Care Choices proposal in his 2020 budget.

The proposal, according to Fishpaw, “would lower premiums by up to a third, lowering costs while also protecting people with pre-existing conditions.” It would replace federal payments to insurance companies with grants for each state, giving individual states more leeway to determine how to use the money.

One conservative policy analyst said that although the White House is definitely “exploring” the healthcare issue, it does not seem ready to unveil a proposal…

Trump has already asked a group of Senate Republicans, including John Barrasso of Wyoming, Rick Scott of Florida and Cassidy to come up with a replacement for Obamacare. But other Senate Republicans, including Sens. Roy Blunt of Missouri, John Kennedy of Louisiana and Majority Leader Mitch McConnell, have indicated an unwillingness to get moving on the issue until Trump puts forth his own proposal.

“I’m anxious to see what the White House is going to recommend in terms of a healthcare delivery system that looks like somebody designed the damn thing on purpose,” Kennedy said.” (I)

“President Donald Trump on Monday night backed away from his push for a vote on an Obamacare replacement until after the 2020 elections, bowing to the political reality that major health care legislation cannot pass in the current Congress.

Trump’s statements come a week after his administration announced that it now agreed with a judge’s ruling that the entire Affordable Care Act should be scrapped. The opinion was a dramatic reversal from the administration’s previous stance that only portions of the act could not be defended.

Trump’s latest move allows him to wait on the issue as legal challenges against the health care law, also known as Obamacare, make their way through the federal court system. If it’s ultimately overturned, Trump can claim he made good on a campaign promise in time for his 2020 re-election campaign — though he would then face the prospect of an estimated 20 million Americans losing their health insurance on his watch, with no Republican replacement in the legislative pipeline. If it’s upheld — as it has been in previous Supreme Court challenges — he can rail against a “liberal” court system…

Trump unsettled Republican lawmakers last week by putting the spotlight back on the thorny issue of repealing and replacing Obamacare, vowing that his party would turn to replacing the health care law as his administration backed a federal court ruling striking down the law in its entirety. Republican congressional leaders quickly sought to distance themselves from Trump’s latest drive, mindful that passing such a proposal would be virtually impossible in a divided Congress…

Trump said Thursday he’s asked Republican senators to work on a replacement to the Affordable Care Act, but no such group appears to exist. Multiple Republican senators who Trump name-checked said they were not a part of a working group, but had spoken with the President about health care recently.

And on Wednesday, Marc Short, Vice President Mike Pence’s chief of staff and the former White House legislative affairs director, claimed on CNN that “the President will be putting forward plans this year” to replace Obamacare through Congress.

White House officials were quick to tell CNN that Short had gotten ahead of White House deliberations.

The White House has yet to decide whether it will take the lead on crafting an Obamacare replacement, they said, or whether the President will punt to Republican lawmakers.” (J)

__________

From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare)

OBAMACARE/ TRUMPCARE CHRONOLOGY

March 26, 2017

LESSONS LEARNED: TrumpRyanCare Obits

March 29, 2017

Let’s prohibit Congressmen from insurance reimbursement for Prostate Screening and Treatment

May 6, 2017

Repeal and DESTROY Obamacare

May 24, 2017

Hard to believe a congressman said NOBODY DIES BECAUSE THEY DON’T HAVE ACCESS TO HEALTH CARE

June 16, 2017

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

June 23, 2017

Is there more “heart” in the Senate health care bill? Or is it “meaner” than the House bill?

June 29, 2017

Perry Como sang “There’s no place like home for the holiday”….except for Republican Senators with their TrumpCare albatross

July 4, 2017

REPEAL NOW/ REPLACE LATER: “Nothing like rolling a hand grenade into ongoing negotiations…”

July 6, 2017

Cruz health care bill amendment – “….healthy people could get coverage although that coverage might not protect them if they got sick and sick people would have to pay an unaffordable amount for coverage.”

July 9, 2017

SLOW DOWN & START OVER (policy) versus REPEAL & REPLACE (politics)

July 12, 2017

What would Albert Einstein have said about TrumpCare? “The definition of insanity is doing something over and over again and expecting a different result.”

July 13, 2017

Is the new Senate health proposal a responsible bill or just “stuff” to get 50 votes?

July 15, 2017

Republican Talking Points on the new Senate Health Care Bill. Democratic Party response – “Senate Republicans spent the past two weeks putting lipstick on a pig”

July 16, 2017

Last week Senator McCain said the “Senate healthcare deal could be reached by Friday ‘if pigs fly’” (A). Now he has a deciding vote on the Republican “junk insurance” bill!

July 17, 2017

“Laws are like sausages, it is better not to see them being made.” (Otto von Bismarck). Or not made…two conservative Republican Senators kill TrumpCare….for now

July 18, 2017

After another day of Republican health care bill fiascos: “President Trump: ‘Let Obamacare Fail…I’m Not Going to Own It’

July 19, 2017

Are Republicans going to LET Obamacare die or MAKE it die? How can the individual market exchanges be stabilized?

July 20, 2017

“The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith.”

July 21, 2017

“McConnell is still planning votes on health-care legislation next week. But many things have to go right for his strategy to succeed, and not all of them are within his control.”

July 22, 2017

“….. the parliamentarian has taken an already very difficult process for enacting health care legislation in the Senate and made it nearly impossible….”

July 23, 2017

New York Daily News editorial: Senate Republican vote –“An embarrassment wrapped in cruelty wrapped in political disaster.”

July 24, 2017

Rep. Blake Farenthold (R-Texas) suggested….that he’d like to duel with female senators he blames for the Senate’s failure to repeal and replace ObamaCare

July 25, 2017

“These are the moments legislatively when you get creative. We’re getting creative.”

July 26, 2017

“It is clear that Mr. McConnell does not much care which of these proposals the Senate passes…. — he just wants to get a bill out of the Senate.”

http://doctordidyouwashyourhands.com/?s=It+is+clear+that+Mr.+McConnell&submit=Go

July 27, 2017

Senator Graham said he could not support a “half-assed” plan that he called “politically” the “dumbest thing in history.”

July 28, 2017

The House and Senate played “dodgeball” not wanting to be held accountable when twenty million people, their constituents, would lose access to affordable care.

July 29, 2017

What Congress, President Trump and Former President Obama are saying about healthcare

August 6th

“.. here’s the first thing I thought about: feel better, Hillary Clinton could be president..” (Senator McConnell) (A) “McCain Voted Against Health Care Bill…Because it Would ‘Screw’ Arizona.” (B)

August 10, 2017

“In politics you can tell your friends from your enemies, your friends are the ones who stab you in the front”.* Look at what the Republicans are saying about each other now about health care

August 16, 2017 |

The Trump administration “blinks”; provides Obamacare funding

http://doctordidyouwashyourhands.com/2017/08/the-trump-administration-will-make-this-months-ob

August 23, 2017

For 17 years I was President and CEO of a safety net hospital. TrumpCare will “disinsure” twenty million+ people and devastate the hospitals we all depend on.

http://doctordidyouwashyourhands.com/2017/08/for-17-years-i-was-president-and-ceo-of-a-safety-net-hospital-trumpcare-will-disinsure-twenty-million-people-and-devastate-the-hospitals-we-all-depend-on/amacare-payments-to-insurers/

August 23, 2017

Trump told a GOP senator she could only ride on Air Force One if she voted for the healthcare bill.

September 3, 2017

TrumpCare. “If you don’t know (`or care`) where you’re going, any road will get you there.” – Lewis Carroll

September 8, 2017

“Republican plans to replace Obamacare are fading fast, but that doesn’t mean Congress is done with health care.

September 16, 2017

“Senators on the health committee are working over the weekend to try to reach an agreement on a stabilization bill for Obamacare…”

September 19, 2017

President Trump would sign the Graham-Cassidy bill if the legislation to repeal Obamacare makes it to his desk…. IT JUST MIGHT MAKE IT THERE!

September 20, 2017

TRUMPCARE. “This is the choice for America, Mr. Graham said on Tuesday: “Socialism or federalism when it comes to your health care.””

September 21, 2017

President Trump tweeted he ”.. would not sign Graham-Cassidy if it did not include coverage of pre-existing conditions. It does! A great Bill. Repeal & Replace.” IT DOESN’T!

September 22, 2017

“It ain’t over till it’s over.” (Yogi Berra). But, John McCain said he “cannot in good conscience vote for the Graham Cassidy proposal.”

September 23, 2017

TrumpGrahamCassidy. “Perhaps one of the biggest challenges for the bill will come next week when the Senate parliamentarian — an umpire of sorts for the chamber’s rules — takes a look at the bill…”

September 24, 2017

White House Director of Legislative Affairs Marc Short is defending the proposed Graham-Cassidy bill — – by countering criticism that the bill does not provide coverage for those with pre-existing conditions.

September 25, 2017

TRUMP/ GRAHAM/ CASSIDY. “If there’s a billion more going to Maine … that’s a heck of a lot,” Cassidy said.

September 26, 2017

“I personally think it’s time for the American people to see what the Democrats have done to them on health care,” said Senate Finance Committee Chairman Orrin G. Hatch (R-Utah).

September 27, 2017

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

September 28, 2017

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

September 29, 2017

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

October 1, 2017

Senator Cassidy a candidate for Health and Human Services Secretary?

October 2, 2017

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

October 8, 2017

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

October 12, 2017

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

October 15, 2017

Trump vows to rip apart Obamacare piece by piece

October 18, 2017

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

October 31, 2017

Ending the subsidy for copays/ deductibles would increase the subsidy for premiums ..and ObamaCare enrollment would grow

November 9, 2017

President Trump and Republican congressional leaders falsely claim that Obamacare… is in a “death spiral.”

November 14, 2017

Senate Republicans include repeal of Obamacare’s individual mandate in the tax bill

November 20, 2017

The Republican deal with itself: repeal the Obamacare individual mandate and stabilize the individual health insurance market?

November 26, 2017

“The White House is trying kill Obamacare. Americans are throwing it a lifeline.”

November 30, 2017 | Edit

“The Senate tax bill is really a health care bill with major implications for more than 100 million Americans…..

December 2, 2017 |

“..Conference Committee “may not change a provision on which both houses agree, nor may they add anything that is not in one version or the other,”…

December 6, 2017

“…House and Senate Republicans will likely scrap Obamacare’s individual mandate in their final tax bill.”

December 8, 2017

..congressional Republicans aim to reduce spending on federal health care programs to reduce America’s deficit

December 10, 2017

Note to Sen Collins: Look Around the Poker Table- If You Can’t See the Patsy, You’re It! *

December 14, 2017

“..the compromise tax bill from House and Senate negotiators will end the health law’s requirement that all individuals buy insurance or pay a fine….”

December 17, 2017

“ the move is a winner for Republicans, who.. would otherwise have little to show for 7 years of…repeated efforts to kill Obamacare..”

December 19, 2017

“….57 % of Americans now approve of Obamacare. Only 29 % approve of the GOP’s tax cuts.”

December 20, 2017

By ending the Individual Mandate Republicans are “showing they have no clue how insurance works.”…or don’tcare…

December 21, 2017

President Trump: “When the individual mandate is being repealed that means ObamaCare is being repealed”

December 23, 2017

“It leaves us with two laws… Call the first one Obamacare… Call the second one Trumpcare”

January 10, 2018

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

January 24, 2018

GOP Rep. Blames Obamacare For Sexual Harassment Allegations

April 25, 2018

From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare)

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From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare

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April 25, 2018 | Edit

On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…”

“Andy Slavitt, who served as the acting administrator for the Center for Medicare and Medicaid Services under President Barack Obama, warned late Friday night that Republicans may try to repeal and replace Obamacare once again before the 2018 midterm elections. “Republicans have been meeting in secret to bring back ACA repeal,” he writes…

… Santorum and others may think that there will be a “blue wave” in 2018 no matter what, so this may be the last time the GOP has the opportunity to get rid of Obamacare. And that might make Republicans desperate enough to try again.” (R)

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

In 2018, mostly under-the-radar, efforts are continuously underway to continue to undermine what’s left of ObamaCare.

“Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it…,

Congress has already repealed several unpopular parts of the law as part of last year’s tax legislation — most notably the individual mandate, which now expires at the end of this year, but also the Medicare cost-control board (known as the Independent Payment Advisor Board).

The executive branch has exerted its own influence on the law. In October of last year, President Trump signed an executive order calling for the expansion of association health plans and limited-duration insurance, in hopes of creating a secondary market for health plans that are cheaper and less regulated, and this year, the administration released extensive proposals for each. The administration also stopped paying the law’s cost-sharing reduction subsidies, which reimburse insurers for low-income beneficiaries. And the Department of Health and Human Services has begun allowing states to attach work requirements to Medicaid, making the program more bureaucratic, but possibly enticing red states that have so far declined to expand the program to do so…

Having failed in their repeal effort, Republicans are now in something of an arranged marriage with the health care law. These alterations are being made in a predictably haphazard fashion, with little in the way of guiding theory, but the cumulative effect is to turn Obamacare into a law that they can, if not love, at least learn to live with.”(A)

“Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options….

People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.

But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure.” (B)

“It’s been well documented that the Trump White House has filled federal agencies with bureaucrats whose life work is destroying the very agencies they’ve been assigned to. But one is in a better position than her fellows to threaten the health of millions of Americans—and she’s been working at that assiduously.

We’re talking about Seema Verma, who as administrator of the Centers for Medicare and Medicaid Services also is effectively the administrator of the Affordable Care Act. In the Trump administration, that has made her the point person for the Trump campaign to dismantle the act, preferably behind the scenes…

Still, Verma had spent enough time in the healthcare field that observers thought she might not be totally egregious as CMS administrator. But then, during her confirmation hearing in February 2017, she let on that she didn’t see why maternity coverage really needed to be mandated for all health policies, since “some women might want maternity coverage, and some women might not want it…

It wasn’t an auspicious start. But since then she has lived down to our expectations. Verma never has concealed her hostility to Medicaid — especially Medicaid expansion, a provision of the ACA. Her animosity is fueled at least in part by ignorance (willful or otherwise) about the program. Back in November, on the very day that voters in Maine and Virginia were demonstrating full-throated support at the polls for expanding Medicaid in their states, Verma was unspooling a string of misleading statistics and suspect assertions about the program to support a policy of rolling back enrollment.” (C)

“Passing two measures aimed at stabilizing the Affordable Care Act marketplaces by infusing insurers with more funds would lower monthly premiums by 20 to 40 percent and prompt an additional 3.2 million people to get covered, says an attention-grabbing independent analysis released yesterday by the firm Oliver Wyman.

These measures – which would pay insurers for extra cost-sharing discounts for the low-income and reimburse them for their most expensive customers – are currently stuck in political limbo as leaders on Capitol Hill consider whether to include them in a massive, must-pass spending bill next week.

The bills have become emblematic of inter and intraparty disputes over how to approach a world with most of the ACA still in place. Democrats are bitter that Republicans are still chipping away at parts of the law by repealing its individual mandate and changing other provisions through the executive branch…

And Republicans can’t even agree among themselves how to handle the law now that they’ve failed to entirely wipe it from the books. (D)

“Republicans campaigned for roughly a decade, promising voters they would dismantle former President Barack Obama’s landmark health care legislation; but one of their own senators is trying to keep it alive through the 2018 election cycle…

Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray, D-Wash., is using the deadline to sway leadership to include a proposal that would fund politically contentious Obamacare subsidies through 2019. The proposal would provide $10 billion a year for three years for these subsidies…

Additionally, the proposal would give states greater Obamacare waiver flexibility and would broaden consumer eligibility for “copper” plans. Abortion-covering health insurance plans would not receive subsidies under the proposal…

Republicans are either not thrilled about Alexander’s proposal, calling it a bad idea and one that could hurt the party going into 2018, or they think it could be one way to provide taxpayers some relief from the financial burdens Obamacare imposed.” (E)

“The House passed the $1.3-trillion omnibus spending package meant to keep the government running until Sept. 30 in a vote of 256-167, leaving the Senate barely 35 hours to get the same legislation approved by Friday at midnight to avert a shutdown.

The bill boosts funding for the National Institutes of Health, the CDC, and the Department of Veterans Affairs (VA) as well as other key agencies, but keeps funding flat for the Centers for Medicare and Medicaid Services…

The bill also does not include the health insurance stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins (R-Maine). They had wanted the omnibus package to include measures restoring for 3 years the cost-sharing reduction subsidies (monies that help insurers defray out-of-pocket costs for low-income enrollees), establishing 3 years of reinsurance (monies that help pay for the sickest of patients and keep premiums from spiking) at $10 billion per year, and streamlining the 1332 waiver process to allow states more flexibility in health plan design.” (F)

“The Trump administration hopes to move forward with a rule expanding alternatives to ObamaCare plans by this summer, Secretary of Labor Alex Acosta said Monday. The rule allows small businesses and self-employed individuals to band together to buy insurance as a group in what are known as association health plans. “We hope to have that by this summer,” Acosta said Monday during a tax reform event alongside President Trump in Florida.” (G)

“In 2012, the Supreme Court of the United States upheld Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority opinion. Many Obamacare opponents believe Roberts used contorted reasoning to save the law by labeling Obamacare’s individual mandate penalty a tax.

Now, six years later, 20 states have seized on the Roberts ruling to ask the courts again to undo Obamacare. These states filed a lawsuit indicating that because the December 2017 tax reform bill repealed the individual mandate penalty, there’s no longer any legal rationale for the mandate. They also argue that because there’s no “severability clause” in Obamacare, the entire law must be struck down.

If this sounds confusing, read on to unpack what’s going on with this latest attempt to undo Obamacare through the courts.

The Obamacare mandate was ruled a tax…

Opponents of the law argued Congress didn’t have the power to require individuals to purchase a product from private insurers, while the Obama administration argued authority for the mandate came from the Commerce Clause, which gives the federal government power to regulate commerce “among the several states.”” (H)

“Gov. Scott Walker has asked for a federal waiver to operate a state-based reinsurance plan designed to stabilize the state’s individual health insurance market and hold down premiums under the Affordable Care Act.

Following a 44 percent average spike in Obamacare premiums this year, Walker’s office estimates the $200 million program would lower premiums by 11 percent from what they otherwise would have been, amounting to a 5 percent decrease in premiums compared to 2018.

Under the plan, the state would pay $34 million for reinsurance in 2019, while $166 million would come from federal funds…

“We are taking action to address the challenges created by Obamacare and bring stability to the individual market,” Walker said. “Our Health Care Stability Plan provides a Wisconsin-based solution to help stabilize rising premiums in order to make health care more affordable for those purchasing in the individual market. With Washington D.C. failing to fix our nation’s health care system, Wisconsin must lead.” (I)

“The American Academy of Family Physicians and other doctor groups have unleashed detailed critiques of Trump’s effort to introduce cheaper health insurance with skimpier benefits….

“Insurers could reduce or eliminate certain essential health benefits to avoid vulnerable, expensive patients by excluding specific services,” AAFP board chair Dr. John Meigs, Jr., a family physician from Alabama wrote in a letter last week to U.S. Health and Human Services Secretary Alex Azar.

“In doing so, insurers could potentially make plans more expensive for people with long-term chronic conditions or with sudden medical emergencies,” Meigs said. “Inadequate benefits could leave this population with too little coverage to meet their health care needs.” (J)

“The Affordable Care Act (aka Obamacare) banned any hospital, doctor, or insurance company who receives federal funding from discriminating against or denying services based on sex; the Obama administration made it clear in 2016 that provision included transgender and gender-nonconforming patients…

These benefits and protections are heading for oblivion though, according to the Times. The Trump administration is pointing to a January 2017 ruling from a Texas federal judge who said the 2010 law did not cover gender identity or presentation.

“Congress did not understand ‘sex’ to include ‘gender identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said, Congress “adopted the binary definition of sex.” (K)

“As Republicans careen toward the midterms with tax reform under their belts and not much else, rumor has it that a small group of Republican senators are working with the White House and former Sen. Rick Santorum (R-Pa.) to revive the debate over ObamaCare repeal.

Their purpose is laudable. But, privately, conservatives across Capitol Hill are expressing concern that the proposal may not do enough to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or allow freedom to innovate outside the law’s stifling framework…

The bill’s premise — to devolve much of the health-care spending to the states — is a good starting point. But its implementing details are still unknown, leaving conservatives to wonder if the new bill will actually repeal ObamaCare and reform the health-care marketplace, or if it will simply recast much of the law’s worst elements with a few minor tweaks…

Voters are still waiting for a full repeal effort. Anything less will not suffice as a solution for candidates who will soon be elected on a message of repeal. Nor will it suffice for a party who has spent years making the same promise.” (L)

“Less than a year after the GOP gave up on its legislative effort to repeal the law, Democrats are going on offense on this issue, attacking Republicans for their votes as they hope to retake the House majority…

ObamaCare’s favorability in polls has improved since the repeal push last year, with more now favoring the law than not. A Kaiser Family Foundation poll in March found that 50 percent of the public favors the law, while 43 percent holds an unfavorable view.

GOP strategist Ford O’Connell said the political winds have shifted on the issue, turning ObamaCare into a subject Democrats want to tout and many Republicans want to duck.

“I don’t think it’s seen as a winning issue,” he said. “It’s also an issue that tends to fire up the Democratic base more so than the Republican base.”” (M)

“While Republican moves to overhaul Social Security, Medicare or Medicaid appear unlikely — at least for this year — Democrats are increasingly warning about the prospect because of the deficit concerns created by the tax plan. The GOP argues Democrats want to distract from the fact that they did not support the tax overhaul, the signature Republican achievement of Trump’s first year in office.

Democrats’ ability to sell voters on their vision for health care and warn about the possibility of cuts to Social Security and Medicare could prove crucial for candidates, such as Manchin, who are trying to win in red areas…

Polling suggests Trump and the GOP’s efforts to reshape the American health-care system have not resonated with voters. Thirty-six percent of respondents to the Economist/YouGov poll said they strongly disapprove of how the president has handled health care, compared with only 15 percent who said they strongly approve.” (N)

“People have voted with their enrollment decisions: A sizable number of Americans do not get insurance from their employers and value the coverage on Obamacare’s markets. That refutes the GOP myth that the program forces Americans to purchase junk insurance that they do not want. A recent Kaiser Family Foundation poll found that these consumers seek to guard against major medical costs, to gain the peace of mind that comes with insurance and to obtain coverage for chronic medical care, suggesting that the law serves important and durable needs.

Another fictional Republican claim is that Obamacare has been collapsing. A Kaiser study this year found that insurance markets stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This comports with findings from the Congressional Budget Office and a range of other independent analysts…

Obamacare continues to serve an important need. What’s sad to see is how easy it would be to make it even more useful, if Republicans would focus on improvement instead of sabotage.” (O)

“What’s the secret of Obamacare’s stability? The answer, although nobody will believe it, is that the people who designed the program were extremely smart. Political reality forced them to build a Rube Goldberg device, a complex scheme to achieve basically simple goals; every progressive health expert I know would have been happy to extend Medicare to everyone, but that just wasn’t going to happen. But they did manage to create a system that’s pretty robust to shocks, including the shock of a White House that wants to destroy it…

What this says to me is that if Republicans manage to hold on to Congress, they will make another all-out push to destroy the act — because they’ll know that it’s probably their last chance. Indeed, if they don’t kill Obamacare soon, the next step will probably be an enhanced program that lets Americans of all ages buy into Medicare.” (P)

“At the outset, Obamacare had three central features:

• Insurers could not charge higher prices to people with pre-existing conditions.

• Those without coverage had to pay a penalty to the government (the “mandate”).

• Low-income people would be eligible for subsidies.

The first two provisions were necessary to prevent the death spiral, and government couldn’t mandate insurance purchases without adding subsidies for the poor.

Despite a bumpy rollout and some frustrations over shrinking choices and rising prices at health care exchanges, Obamacare was working remarkably well by most important metrics. Program costs were much lower than expected, and the uninsured rate among nonelderly Americans fell sharply — from 18.2 percent in 2010 to only 10.3 percent in 2018.

This progress is now imperiled.

The mandate — by far the program’s least popular provision — was repealed as part of tax legislation passed in December 2017. And because economists predict that its absence will slowly rekindle the insurance death spiral, we’re forced back to the policy drawing board… (Q)

SEE OBAMACARE/ TRUMPCARE CHRONOLOGY AFTER THE FOOTNOTES

(A) The G.O.P. Accidentally Replaced Obamacare Without Repealing It, by Peter Suderman https://www.nytimes.com/2018/03/12/opinion/republicans-obamacare-health-care.html

(B) Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It., by Margot Sanger-Katz, https://www.nytimes.com/2018/04/11/upshot/republicans-couldnt-knock-down-obamacare-so-theyre-finding-ways-around-it.html

(C) How Trump’s Obamacare administrator is taking a hatchet to Obamacare, by Michael Hiltzik, http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-verma-20180417-story.html

(D) The Health 202: Republicans could lower Obamacare premiums. But will they?, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/03/13/the-health-202-republicans-could-lower-obamacare-premiums-but-will-they/5aa6a81330fb047655a06c0d/?utm_term=.923a4143e8d5

(E) Senate May Fund Obamacare Subsidies With This Sneaky Move, by Robert Donachie, https://www.dailysignal.com/2018/03/15/senate-is-going-to-fund-obamacare-subsidies-with-this-sneaky-move/

(F) House Passes Spending Bill Without Obamacare Fix, by Shannon Firth https://www.medpagetoday.com/publichealthpolicy/healthpolicy/71945

(G) Trump Official: Alternative to ObamaCare Plans Likely This Summer, by Peter Sullivan, http://galen.org/2018/obamacare-watch-newsletter-4-20-18/

(H) States Take Another Run at Undoing Obamacare Through the Courts, by Christy Bieber, https://www.fool.com/investing/2018/04/22/states-take-another-run-at-undoing-obamacare-throu.aspx

(I) Amid rising Obamacare premiums, Walker seeks federal waiver for reinsurance program, by op 5 percent, by Lauren Anderson, https://www.biztimes.com/2018/ideas/government-politics/amid-rising-obamacare-premiums-walker-seeks-federal-waiver-for-reinsurance-program/

(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of Comment Deadline, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2018/04/22/doctors-attack-trumps-short-term-health-plans-ahead-of-comment-deadline/#9049bad3fb10

(K) Trump to Allow Anti-Trans Discrimination in Health Care, by BY NEAL BROVERMAN, https://www.advocate.com/transgender/2018/4/22/trump-allow-anti-trans-discrimination-health-care

(L) Republicans have a long way to go toward fully repealing ObamaCare, by Rachel Bovard, http://thehill.com/opinion/healthcare/383722-republicans-have-a-long-way-to-go-toward-fully-repealing-obamacare

(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN, http://thehill.com/policy/healthcare/384032-gop-in-retreat-on-obamacare

(N) It’s not all about Trump: Democrats’ midterm chances ride on health care and Social Security, too, by Jacob Pramuk, https://www.cnbc.com/2018/04/16/not-just-trump-health-care-social-security-could-define-2018-midterm-elections.html

(O) Americans are sticking by Obamacare. If only the GOP would stop trying to kill it., https://www.washingtonpost.com/opinions/americans-are-sticking-by-obamacare-if-only-the-gop-would-stop-trying-to-kill-it/2018/04/15/9b817832-3c2b-11e8-a7d1-e4efec6389f0_story.html?noredirect=on&utm_term=.e10e892994e9

(P) Obamacare’s Very Stable Genius, by Paul Krugman, https://www.nytimes.com/2018/04/09/opinion/obamacare-trump.html

(Q) Back to the Health Policy Drawing Board, by ROBERT H. FRANK, https://www.nytimes.com/2018/03/16/business/back-to-the-health-policy-drawing-board.html

(R) Health Policy Expert Says Republicans Have ‘Secret’ Plan to Repeal Obamacare, by Cody Fenwick, https://www.alternet.org/news-amp-politics/health-policy-expert-says-republicans-have-secret-plan-repeal-obamacare 000000000000000

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