As you may have figured out by now I follow information about the health care industry pretty closely. As a hospital CEO for seventeen years, the New York Times, Newark Star Ledger and Jersey Journal were on my desk every morning when I walked in the door. Then as an adjunct professor in two graduate programs, and with the instantaneity of the internet, I got about a half a dozen news updates and summaries immediately, daily and weekly. But even with this constant immersion, sometimes articles are so compelling that I have to stop and think about the implications. This happened recently.
I was startled (and reminded) by a New York Times article “Medical Errors May Cause Over 250,000 Deaths a Year” which noted: “If medical error were considered a disease, a new study has found, it would be the third leading cause of death in the United States, behind only heart disease and cancer.
“Medical error is not reported as a cause of death on death certificates, and the Centers for Disease Control and Prevention has no “medical error” category in its annual report on deaths and mortality. But in this study, researchers defined medical error as any health care intervention that causes a preventable death.
For example, in one case a poorly performed diagnostic test caused a liver injury that led to cardiac arrest, but the cause of death was listed as cardiovascular. In fact, the cause was a medical error. Diagnostic errors, communication breakdowns, the failure to do necessary tests, medication dosage errors and other improper procedures were all considered medical errors in the study.” (A)
Soon after a Washington Post article “Exclusive: Patient safety issues prompt leadership shake-up at NIH hospital,” noted: “The National Institutes of Health is overhauling the leadership of its flagship hospital after an independent review concluded that patient safety had become “subservient to research demands” on the agency’s sprawling Bethesda campus.
The shake-up at the NIH Clinical Center, which was announced to staff Tuesday, represents the most significant restructuring at the nation’s premier biomedical research institution in more than half a century.
NIH Director Francis Collins said he will replace the hospital’s longtime leadership with a new management team with experience in oversight and patient safety, similar to the top structure of most hospitals….” (B)
These articles sent me looking for a 2007 classic book – “How Doctors Think” (C) by Dr. Jerome Groopman, Chairman of Medicine at Harvard Medical School.
Discussing actual cases from his own clinical practice, Dr. Groopman developed a classification system for medical mistakes, observing a tendency to treat a case based on past experience rather than looking at it based solely on the evidence.
“Vertical Line Failure – thinking inside the box
Confirmation Bias – confirming what you expect to find by selectively accepting or ignoring information
Anchoring –the failure to consider multiple possibilities but quickly and firmly latching on a single one
Availability –an unusual event that recently occurred which has similarities to the current case causing MD to ignore important differences
Commission Bias – tendency toward action rather than inaction due to “bravado”, desperation, or patient pressure
Relying on “Strict Logic” – answering a clinical question in the absence of empirical data
Over-reliance on Clinical Algorithms – simply filling in the blanks on the template
Haste – complicated problems cannot be solved quickly
Outcome Bias – thinking that the diagnosis that is wished for has occurred• Limited Searching –stop searching for a diagnosis once “
This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes.
The point is we all fall into comfortable patterns of thinking – our own default classification systems.
“President Trump has downplayed the scale of the disaster in Puerto Rico, where the official death toll now sits at 45. But hospital employees, funeral directors, and healthcare volunteers in Puerto Rico who spoke to VICE News put the count much higher. They’re not only overwhelmed with bodies — often whose cause of death hasn’t been determined — but officials might not be accounting for deaths indirectly related to Hurricane Maria, like those due to medication shortages.
VICE News called all 65 hospitals in Puerto Rico listed on the U.S. government’s website. At least one hospital had permanently closed, and others’ phone lines had been disconnected. Many had administrative employees unable to show up to work, while others were running on inconsistent flow of water and diesel to power generators. At most hospitals, however, the morgues were filling up beyond capacity, making the death count difficult to track. (A)
“Nearly three weeks after Hurricane Maria tore through Puerto Rico, many sick people across the island remain in mortal peril. The government’s announcements each morning about the recovery effort are often upbeat, but beyond them are hidden emergencies. Seriously ill dialysis patients across Puerto Rico have seen their treatment hours reduced by 25 percent because the centers still lack a steady supply of diesel to run their generators. Less than half of Puerto Rico’s medical employees have reported to work in the weeks since the storm, federal health officials said.
Hospitals are running low on medicine and high on patients, as they take in the infirm from medical centers where generators failed. A hospital in Humacao had to evacuate 29 patients last Wednesday — including seven in the intensive care unit and a few on the operating table — to an American military medical ship off the coast of Puerto Rico when a generator broke down….
Matching resources with needs remains a problem. The Puerto Rico Department of Health has sent just 82 patients to the Comfort over the past six days, even though the ship can serve 250. The Comfort’s 800 medical personnel were treating just seven patients on Monday.” (B)
“Medicaid block grants have been a centerpiece of Republican health proposals for more than a decade. Proponents, including House Speaker Paul Ryan (R-WI), argue that giving states a fixed amount of money through a block grant or per-person limit with few strings attached gets Washington out of the way and allows for state innovation. Although the most recent block grant legislation did not reach the Senate floor, proponents have promised to continue to push for it.
But one need look no further than the growing health crisis in Puerto Rico to understand why capped federal money and state flexibility will not solve serious health care issues.
Unlike states, Puerto Rico’s federal Medicaid funding is provided through a lump sum of federal funds: a block grant. Over the years, this approach has proven insufficient to address the island’s significant health needs. Even before Hurricanes Maria and Irma, Puerto Rico faced significantly higher rates of chronic diseases such as coronary heart disease and asthma, as well as higher rates of premature births and infant mortality, compared to rates in the mainland United States. The supply of available providers, particularly for specialist services, is below average. (C)
“Florida Hospital Oceanside remains closed indefinitely, more than a month after Hurricane Irma blew through the area and damaged the 80-bed facility located on State Road A1A on the beachside. It’s not clear when — or even if — the hospital will reopen….
“Florida Hospital Oceanside sustained significant damage both to the exterior and interior of the facility,” he continued. “We are in the process of determining the feasibility of renovations and will update you as the situation unfolds.”
Florida Hospital Oceanside is the smallest of six hospitals the not-for-profit Adventist Health System operates in Volusia and Flagler counties, and it is the chain’s only major facility in Ormond Beach. The hospital’s main focus is on providing occupational, physical and speech therapy rehabilitation services to patients. (D)
“Five years ago this month, the lights went out in New Jersey as Superstorm Sandy roared ashore and wiped out electricity for days….
NJHA works closely with a network of agencies from the emergency response, public safety, public health and social services sectors to make sure we’ve planned and drilled for all types of emergencies.
We developed our Weathering the Storm planning guide with detailed checklists of 400-some items that health care facilities must consider before, during and after a weather emergency. For example, it’s not enough to just anticipate for enough staff to care for our patients and residents. We plan for getting them into place ahead of time, providing them space to sleep and shower, fueling up their vehicles and securing law enforcement escorts if roads are closed. We even plan to make sure our staffs’ family members and pets are cared for — so that they can focus on being there for their community….(E)
“On Oct. 1, the deadliest mass shooting in modern American history occurred in Las Vegas, Nevada, killing 59 people and injuring over 520 others. In the wake of the tragedy, hospitals and trauma centers across the region swung into action — and in the aftermath, witnesses, doctors and patients are describing scenes of intense, bloody chaos as medical staff performed one of the biggest life-saving efforts in recent American memory. Many people are wondering what it’s like inside a hospital after a mass shooting, and the stories that are emerging after what’s now being called the Mandalay Bay Shooting are as horrific as they are heroic.
Nevada has only one level-one trauma center, a 24-hour trauma care clinic capable of coping with waves of critically injured patients. The University Medical Center just last week dealt with 15 trauma cases in one night. After the tragedy in Las Vegas, it was sent hundreds of cases, arriving from the Route 91 Harvest Festival in various states of injury by any means necessary. The narratives emerging from within the UMC and other hospitals and medical centers around Nevada, all of whom responded immediately as news of the massacre spread, are deeply distressing, so this is not the account for you if you’re struggling to deal with a traumatic reaction to the events of Sunday night. But more than anywhere else, perhaps, the inside of a hospital responding to a mass shooting gives lessons about the real impact of gun violence on American people. These are stories that need to be heard. (F)
“Those injured in the mass shooting on the Las Vegas Strip will undoubtedly be confronted with medical bills, and some area hospitals are stepping up to ease those patients’ financial worries.
On top of various donation drives, University Medical Center, Sunrise Hospital and Dignity Health-St. Rose Dominican will assist shooting victims to pay varying amounts of their hospital costs.
“At Dignity Health-St. Rose, our focus remains on the immediate medical and supportive care needs of the injured as well as their long-term healing process,” said Jennifer Cooper, Dignity Health-St. Rose Dominican spokeswoman. “St. Rose does not intend to bill or require payment from any patient victims of this tragic event.”
To recoup some of the cost, the medical group will look to other avenues to pay for the shooting victims’ care. “St. Rose will bill third-party payers (if any) and will be accepting contributions from donors in the community to address the financial and other burdens placed on these patient victims,” Cooper said.
UMC officials said they will work to help those who were uninsured so they will not have a financial burden. “Because we have had an outpouring of support for our patients, we are closely coordinating uninsured expenses with generous donors,” UMC spokeswoman Danita Cohen said.” (G)
“Air Force Maj. Charles Chesnut was asleep when Stephen Paddock opened fire on a crowd at a concert outside the Mandalay Bay hotel in Las Vegas just after 10 p.m. on Sunday.
About 90 minutes later, he was woken up by an alert to avoid the city’s downtown area.
Despite that warning, Chesnut, a general surgeon assigned to the 99th Medical Group at Nellis Air Force Base, met his commander and headed toward the scene.
He arrived at University Medical Center of Southern Nevada around midnight, as treatment for the first wave of patients was wrapping up.
But his work was just beginning.
“Within two hours after the incident, all the resuscitation bays [at the hospital] were full, and six patients were being operated on by trauma surgeons,” Chesnut said in an Air Force interview.
Air Force Col. Brandon Snook was another surgeon working at the University Medical Center during the aftermath of the shooting.
“Days like we experienced at UMC are the toughest ones, when you have multiple patients injured while multiple patients are continuing to come to the hospital,” said Snook, a surgeon from the 99th Medical Group.
Chesnut said that doctors treated over 100 patients, most from gunshot wounds, as well as some patients who were trampled. (H)
“They streamed in in droves, arriving any way they could: via ambulance, crammed into the backs of trucks, even on foot. Many were in desperate need of care, their bodies punctured by high-velocity gunshots more frequently seen on the battlefield than on the Las Vegas Strip.
After the worst mass shooting in modern U.S. history, victims shot at a music festival on the Strip on Sunday night quickly filled Las Vegas’ hospitals on a scale that many medical personnel said they had never before witnessed — in both the sheer number of patients and the extent of their injuries.
But thanks to regularly held mass casualty training sessions at their hospitals, attending to the victims went as smoothly as possible, they said….
Sunday night’s massacre by a gunman who unleashed a rapid-fire barrage of bullets from the 32nd floor killed at least 58 people and injured almost 500 others, pushing hospitals to the brinks of their capacity.
At Sunrise, which treated 214 patients, “probably a hundred percent” had gunshot wounds, Scherr said. A lot had bone fractures and injuries to their extremities, he said. Others were in more dire condition.
“It’s the art of triage in mass casualty to find the sickest patient and to treat that patient first and get to the less acute patient a little later,” Scherr said.
The sickest arrived first, in ambulances, he said. Then other patients started coming in in makeshift emergency vehicles: trucks and cars driven by ordinary people.” (I)
“In situations where it’s not clear if a shooter has been subdued, medical staff have to make choices about protecting their own safety. Emergency workers, the New York Times reports, went to the site of the shooting to help triage patients and get them to hospital while wearing ballistic helmets and protective clothing to avoid being shot themselves. Paramedics are also trained to avoid attracting attention; Amber Ratto told The Guardian that she and her colleagues turned off their vehicle lights and worked in darkness so as not to attract attention and risk further injury for their patients, or death themselves…
Medical staff went beyond their limits. The Chicago Tribune reports that pediatric surgeons operated on adults and obstetricians diagnosed trauma patients, while some surgeons were performing five operations simultaneously. One surgeon, Jay Coates, told the Associated Press, “I have no idea who I operated on. They were coming in so fast, we were taking care of bodies. We were just trying to keep people from dying. Every bed was full. We had people in the hallways, people outside and more people coming in.” Many patients came in unidentified, so names were assigned at random. Staff worked shifts back-to-back, and volunteers showed up to provide them with water and food.
Supplies were under constant pressure. UMC didn’t have enough X-ray machines; at one point, the supply of chest tubes ran critically low and a nearby hospital ran them over on the back of a pickup truck, according to the Tribune. The New York Times reported that they also faced critical shortages of IV tubing, fluids, blood pressure cuffs and blankets. And medical staff were also operating under extreme psychological pressure. Stahl wrote that “probably the hardest thing I saw” was the police officer who died at his hospital…” (J)
“The UNLV School of Medicine has also played a vital role in the response. The school sent 76 residents and fellows to assist the hundreds of victims, most going to UMC.
There were 30 emergency medical residents, 28 general surgery residents, eight orthopedic residents, three plastic surgery residents, three surgical critical care (fellows) and three acute care (fellows) used from UNLV.
Fildes, who also serves as the chairman of the department of surgery at the UNLV School of Medicine, said the UNLV students augmented the hospital’s response.
“On any given night if you were to come and visit us at the trauma center, we would have a dozen or so victims of car crashes, gunshots or stab wounds,” he said. “But to have over 100 at once, you have to have the ability to amplify your staff.” (K)
“Officials said Las Vegas emergency responders spent years training for a mass casualty event before the music festival massacre.
Las Vegas Review-Journal reported that emergency crews responded within five seconds, and used knowledge learned from past mass casualty events to prepare for such an incident
“We knew what to do,” Clark County Fire Department Chief Greg Cassell said. “It was much grander than we ever envisioned. However, we were able to handle it because of our people, our training, our professionalism and our equipment and our relationships.”…
Drills for hospitals, hotels, schools and malls were put into place, “Because that’s where historically these things are taking place,” according to Chief Cassell.
Chief Cassell said responders transported almost 200 people to hospitals, with a wide range of injuries such as high-powered gunshot wounds, sprains, trampling injuries and cuts.
Chief Cassell praised everyone involved who risked their lives to rescue people. “They performed wonderfully under fire, literally under fire, taking care of patients that were right there in front of them in a drastic, very bad situation,” he said.” (L)
“In the days after the shootings at the Route 91 Harvest festival in Las Vegas, many stories emerged of bystander courage. Volunteers combed the grounds for survivors and carried out the injured. Strangers used belts as makeshift tourniquets to stanch bleeding, and then others sped the wounded to hospitals in the back seats of cars and the beds of pickup trucks.
These rescue efforts took place before the county’s emergency medical crews, waylaid by fleeing concertgoers, reached the grassy field, an estimated half-hour or more after the shooting began. When they did arrive, the local fire chief said in an interview, only the dead remained.
“Everybody was treating patients and trying to get there,” Chief Gregory Cassell of the Clark County Fire Department, said of his personnel. “They just couldn’t.”
The experiences in Las Vegas have implications for the nation. Emergency medical services have changed how they respond to mass attacks, charging into insecure areas and immediately helping the injured rather than standing back. Still, every minute counts, and bystanders can play a critical role in saving lives, as shown in the aftermath to the shooting on Oct. 1 outside the Mandalay Bay Resort and Casino.
“The city functioned as a trauma center,” said Dr. Sean Dort, a surgeon at Dignity Health-St. Rose Dominican Hospital’s Siena campus in nearby Henderson, Nev. “What really makes this unique is the volume.” (M)
“The types of injuries you’re talking about responding to in a mass casualty event are the types of injuries we see here every day, it’s just that there are substantially more of them,” said Miller, a trauma surgeon at University of Louisville Hospital. “So when it comes to preparing for something like this, it’s always in the back of your head.”
Not only is University of Louisville Hospital the only Level 1 adult trauma center in Louisville—it’s the only Level 1 trauma center in a 70-county area spreading south into Kentucky and north into Indiana. The “Level 1” designation indicates the facility is capable of providing the highest level of surgical care for trauma patients, and University of Louisville Hospital is staffed 24/7 to deal with traumatic injuries–everything from car accidents to workplace explosions.
And in the event there’s a mass shooting or any large-scale disaster in the region, this sterile space would quickly be filled with patients, and extend into a nearby hallway and other areas.
Level 1 trauma centers are equipped to handle major trauma, like gunshot wounds. Level 2, 3 and 4 trauma centers have fewer capabilities.
In Kentucky, hospitals and first responders have contingency plans if something were to happen. The people with the most traumatic of injuries – like a gunshot, knife wound or severe burn – would go to University Hospital. If children are involved, they’d go to Norton Children’s Hospital downtown, where there’s a Level 1 trauma center for kids. And Miller said other hospitals in the area would take on patients with less severe injuries.
“This isn’t a single hospital response to this [a mass shooting or other disaster] – this is a community-wide, and a regional, sometimes state-wide approach,” Miller said. (N)
“The initial chaos requires quick, creative incident mitigation solutions, while recovery requires long-term
The massive fires in Northern California have stressed the area’s emergency response system beyond its very limits. Since the night of Oct. 9, thousands of public safety personnel have been working steadily to save tens of thousands of lives.
“Several observations are emerging from this incident even as it continues to unfold:
Chaos reigns supreme in the first moments. When the fires began racing down toward the populated areas, crews scrambled to rescue hundreds of infirm people from nursing homes, hospitals and other medical facilities in the path of destruction. EMS crews reported that patients were being loaded into ambulances, busses and private vehicles as buildings began burning. Local communications began to fail as radio towers were destroyed in the fire zone. The 911 dispatchers were overwhelmed by calls for assistance, both from affected areas as well as the rest of the system. Additional resources will not arrive soon enough to assist during the first moments, requiring rapid out-of-the-box thinking for incident mitigation.
The EMS system must continue functioning. Calls for service continued to flood the system even while fire victims were being treated. We were able to staff up quickly, sending literally every piece of rolling stock into the field to expand coverage and fill gaps created by the fire situation.
Major incidents require planning for the long game. Within the first few hours, the number of EMS vehicles on scene grew exponentially. It became apparent that many were not needed at the time, but that there would be long-term needs for transportation during patient relocation and general repopulation of the community. Several strike teams were demobilized and went home fairly early.
Closing a hospital during a disaster has major ramifications for the EMS system. Beyond the initial evacuation needs, the remaining hospitals have been inundated with patients both in and outside the affected areas. The threat of evacuation of at least one of these facilities kept it from admitting patients to the floors. As a result, the number of inter-facility transfers rose dramatically during the initial phase of the incident. Moreover, re-opening a hospital is incredibly challenging and takes much longer than anticipated. (O)
“On June 12, 2016, a shooter opened fire on Pulse Nightclub in Orlando, Fla., killing 49 and injuring 58 more. At the time, it was the deadliest terrorist strike in the U.S. since the September 11 attacks and the nation’s deadliest mass shooting. All of the victims were rushed to Orlando Health, where CEO David Strong’s team was charged with not only caring for dozens of critically injured patients, but navigating the aftermath of unprecedented tragedy..
He says the only way an organization can be prepared to respond to a crisis such as the Pulse shooting is to ensure every member of the staff feels as though they are part of a team. Only with a strong sense of duty and community can a hospital handle the seemingly insurmountable task of providing necessary patient care. This kind of environment is established from the top down, and Mr. Strong made it clear that teamwork extends beyond clinicians.
“It takes a team. That day, there were security guards, nurse techs, nurses, physicians that were working well beyond what they would typically do. There were administrators getting supplies — it took a team,” Mr. Strong said. “It takes a team every day in healthcare. We think about the outstanding clinicians, but if the operating room isn’t cooled properly, then the operation can’t occur. It confirms that in healthcare, a good functioning team is essential in making things great.”” (P)
(A) Not even hospitals in Puerto Rico know how many people have died, by Alexa Liautaud, https://news.vice.com/story/not-even-hospitals-in-puerto-rico-know-how-many-people-have-died
(B) Puerto Rico’s Health Care Is in Dire Condition, Three Weeks After Maria, by FRANCES ROBLESO, https://www.nytimes.com/2017/10/10/us/puerto-rico-power-hospitals.html
(C) The Insufficiency Of Medicaid Block Grants: The Example Of Puerto Rico, by Vikki Wachino and Tim Gronniger, http://healthaffairs.org/blog/2017/10/12/the-insufficiency-of-medicaid-block-grants-the-example-of-puerto-rico/
(D) A month after Irma, Florida Hospital Oceanside still closed in Ormond Beach, http://www.news-journalonline.com/news/20171012/month-after-irma-florida-hospital-oceanside-still-closed-in-ormond-beach
(E) The New Jersey health care community played a critical role during Superstorm Sandy and its aftermath., By Aline Holmes, http://blog.nj.com/new_jersey_hospital_association/2017/10/weathering_hurricanes_what_san.html
(F) What Is It Like In A Hospital After A Mass Shooting? Trauma Centers Now Need To Be Prepared For Large Scale Attacks, by JR Thorpe, https://www.bustle.com/p/what-is-it-like-in-a-hospital-after-a-mass-shooting-trauma-centers-now-need-to-be-prepared-for-large-scale-attacks-2781862
(G) Local hospitals working to help shooting victims with medical expenses, by Mick Akers, https://lasvegassun.com/news/2017/oct/11/las-vegas-hospitals-help-shooting-victims-expenses/
(H) ‘The kind of thing that happens … in Iraq or Syria’: An Air Force surgeon describes the response to Las Vegas shooting, by Christopher Woody, http://www.businessinsider.com/air-force-surgeon-describes-response-to-las-vegas-attacks-2017-10
(I) Las Vegas Shooting: Hospitals Tested by ‘Wave After Wave’ of Wounded, by Miguel Almaguer and Elizabeth Chuck, https://www.bustle.com/p/what-is-it-like-in-a-hospital-after-a-mass-shooting-trauma-centers-now-need-to-be-prepared-for-large-scale-attacks-2781862
(J) Extraordinary recounting of the rush to save lives at a Las Vegas hospital https://www.washingtonpost.com/national/health-science/as-the-wounded-kept-coming-hospitals-dealt-with-injuries-rarely-seen-in-the-us/2017/10/03/06210b86-a883-11e7-b3aa-c0e2e1d41e38_story.html
(K) Hospitals: ‘No training on earth that will prepare you for this’, by YASMINA CHAVEZ, https://lasvegassun.com/news/2017/oct/07/hospitals-no-training-on-earth-that-will-prepare-y/
(L) Officials: Las Vegas responders trained extensively for mass casualty event, https://www.ems1.com/mass-casualty-incidents-mci/articles/332978048-Officials-Las-Vegas-responders-trained-extensively-for-mass-casualty-event/
(M) After the Las Vegas Shooting, Concertgoers Became Medics, By SHERI FINK, https://www.nytimes.com/2017/10/15/us/las-vegas-shooting-civilian-first-aid.html
(N) In Wake Of Las Vegas, Louisville Hospitals Say They Try To Prepare For Mass Shooting, By Lisa Gillespie, https://wfpl.org/louisville-hospitals-say-theyre-prepared-for-mass-shooting/
(O) 6 takeaways from the California wildfires, by Arthur Hsieh, https://www.ems1.com/fire-ems/articles/334298048-6-takeaways-from-the-California-wildfires/
(P) Orlando Health CEO David Strong on the details of crisis response few people anticipate, by Leo Vartorella , https://www.beckershospitalreview.com/hospital-management-administration/orlando-health-ceo-david-strong-on-the-details-of-crisis-response-few-people-anticipate.html
“The president promised two months ago that his administration would “spend a lot of time, a lot of effort and a lot of money on the opioid crisis.”
Sens. Elizabeth Warren (D-Mass.) and Lisa Murkowski (R-Alaska) are pushing President Donald Trump to formally declare the opioid epidemic a national emergency, something he promised in August but has yet to do.
It’s been 63 days since Trump verbally referred to the opioid crisis as a “national emergency,” the senators noted in a letter they sent to the president Thursday.
“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency. It’s a national emergency,” Trump told reporters while at his golf club in Bedminster, New Jersey. He said his administration was “drawing documents now” and planned “to spend a lot of time, a lot of effort and a lot of money on the opioid crisis.”
Declaring the national emergency would allocate more federal funding to state and local officials dealing with the crisis, as well as pressure lawmakers to take more long-term steps. But no documents have been filed, and the administration hasn’t said when Trump will make an official declaration.
White House press secretary Sarah Huckabee Sanders said in September that the delay was due to “a much more involved process,” and cited legal and administrative issues.” (A)
“New Jersey Gov. Chris Christie said Tuesday President Trump’s failure to officially declare the opioid crisis a national emergency was “not good,” according to a report.
“I think the problem is too big to say that if he had declared an emergency two months ago that it would make a significant difference in two months,” Christie said, per the Associated Press. “But I would also say you can’t get those two months back. And so it’s not good that it hasn’t been done yet.”
The two-term Republican governor chairs Trump’s Commission on Combating Drug Addiction and the Opioid Crisis, which was established in March via an executive order to specifically tackling the opioid epidemic that the body estimates claims about 142 Americans every day.
When asked about the delay, Christie said he had been told by the White House that there were “legal” issues involved with making such a declaration since it was not a natural disaster and had no firm end date.
Christie, however, added that the inaction had “lessened” the commission’s work as one of the key recommendations it made in a July draft report was to name the problem a national emergency.” (B)
“At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.
The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.
Drugmakers, pharmaceutical distributors, pharmacies and doctors have come under intense scrutiny in recent years, but the role that insurers — and the pharmacy benefit managers that run their drug plans — have played in the opioid crisis has received less attention. That may be changing, however. The New York State attorney general’s office sent letters last week to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.
ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.
In contrast, almost every plan covered common opioids and very few required any prior approval.
The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.” (C)
“Nationally, according to the Centers for Disease Control and Prevention (CDC), a baby is born suffering from opioid withdrawal every 25 minutes.
Dayton Children’s Hospital has a program for such babies — a result of the mother using drugs like heroin or other opioids, like painkillers or fentanyl, while pregnant. The hospital’s neonatal intensive care unit treats 20 to 30 babies a year with an average stay of 17 days, down from 58 in 2012. In a hospital where the norm was once broken bones and the flu, the impact of the opioid epidemic is felt in every corner.
Ashley Hudson’s 12-day-old daughter A’Layjah was undergoing treatment at Dayton’s neonatal ICU in September. Her newborn son passed away last year, and she blames her drug use. “I can’t live through that again,” Hudson said.
Hudson said she stopped using heroin during this pregnancy but was treated with a maintenance drug that left A’Layjah born dependent. The unit was helping to treat the baby girl with both medicine and nonpharmacological measures — including low lighting and skin-to-skin bonding — and doctors said her prognosis was good.
For those infants born dependent on opioids, there’s a follow-up clinic, or developmental pediatrics program, where Jude Seidler, a precocious 2-year-old, was making his presence known one day last month.
Jude’s mother had used heroin every day of her pregnancy, and at nine days old, he went home with adoptive parents, Jay and Ashley Seidler. Dayton Children’s Hospital, they say, has been their lifeline.
“We’ve been able to chart his progress,” Jay Seidler said.” (D)
The data show that the situation is dire and getting worse. Until opioids are prescribed more cautiously and until effective opioid addiction treatment becomes easier to access, overdose deaths will likely remain at record high levels.
The opioid epidemic in 6 charts, by ANDREW KOLODNY, https://www.cbsnews.com/news/opioid-epidemic-in-6-charts/
“The national opioid crisis is a dilemma of dichotomies. There are challenges with both prescription and illicit drugs. The solutions must consist of efforts that realistically can reduce the number of people who become addicts in the first place, as well as cure those who do. The underlying issue of pain management can, in many cases, be addressed without drugs or certainly with less addictive formulations. There are public health challenges of both improving the treatment of pain and at the same time reducing the potential for addiction. Clearly, there are choices that can be made for suffering patients that are proven to be effective without the high risks associated with the powerful prescription opioids available today.
For all these issues, data specialists in the medical field can and must become key participants in our solutions effort. These data intelligence engineers can lead the development of fact-based plans of action that are capable of producing real change — change that results from the development of sophisticated data mining and pattern-matching algorithms that target factors associated with addiction. These algorithms can speed up the evaluation and viability of strategies that focus on reducing the death rate immediately and lowering the number of potential addicts in the future. It’s a huge task, but one that a new generation of data analytics tools can handle.” (E)
“The University of Pittsburgh’s Program Evaluation and Research Unit (PERU) is working with Pennsylvania officials to standardize death data from overdose victims.
“It’s represented by age, by gender, by ethnicity, by location,” Dr. Janice Pringle, PERU director, told Fox News.
The purpose of the project, Overdose Free PA, is to provide more detailed reporting in real-time that could help show where the problem areas are, Pringle said. Previously, each coroner’s office had a unique way of recording data on overdose victims, but the project provides them with a template for a standardized option of data reporting.
“That helps you understand that in certain parts of the state there may be patterns,” she told Fox News.
The data is also divided by the type of overdose death, including drugs that are not opioids, like cocaine and LSD, according to the website.
In 2016, there were 4,652 drug overdose deaths in the state, according to a Drug Enforcement Administration report. That equates to roughly 13 drug-related deaths per day.
Specifically, the study found the presence of an opioid, either illicit or prescribed by a doctor, in 85 percent of drug-related overdose deaths in the Keystone State.
Pringle said they’ve already seen the program’s impact in some areas.
“We do have a couple of counties in Pennsylvania that are stabilizing with their overdose rates,” she said.” “(F)
“The headlines from the opioid epidemic seem to be all about overdoses in public parks, homes, and elsewhere in the community. But the drugs can cause problems even in a setting where patients are under the direct care of doctors and nurses: the hospital.
Among the most common trouble spots:
Administration. These events included cases in which patients were given the wrong type of medication, such as a fast-release drug when the slow-release version was indicated. They also included events with the wrong frequency or dose of a drug, incorrect or omitted documentation, administration of opioids without an order, or inadequate patient assessment at administration.
Diversion. These cases include those in which opioids were “unsecured” or where the amount on the shelf did not match records. They also included removal of opioids without documentation that were given to a patient and the failure to account for disposal of leftover drugs.
Prescribing. Problems included prescribing more than one drug at a time or the wrong dose of a drug, and filling duplicate orders of drugs.” (G)
“Families across the United States are demanding that more be done to end the despair and devastation of addiction. Here are eight steps to take — now. They include some of the recommendations of the president’s commission….
SAVE LIVES Active users need to be kept alive long enough to seek treatment…
TREAT, DON’T ARREST Nearly 300 law enforcement agencies..participate in the Police Assisted Addiction and Recovery Initiative, which offers treatment for drug users who ask the authorities for help…
FUND TREATMENT Repealing Obamacare would eliminate Medicaid-funded treatment for thousands of addicts…
COMBAT STIGMA Misunderstanding of opioid addiction shrouds nearly every effort to reduce its toll…
SUPPORT MEDICATION-ASSISTED TREATMENT One of the most effective methods of treating drug addiction is through continuing medication therapies like methadone, naltrexone and buprenorphine…
ENFORCE MENTAL HEALTH PARITY Half to 70 percent of people with substance abuse problems also suffer from depression, post-traumatic stress or other mental health disorders…
TEACH PAIN MANAGEMENT The opioid crisis is rooted in our health care system: American physicians prescribe opioids for pain management at far higher rates than physicians prescribe them in any other nation.
START YOUNG WITH PREVENTION A 2015 study by the National Institute on Drug Abuse found that “Life Skills Training” for seventh graders helped them avoid misusing prescription opioids throughout their teenage years…. “(H)
“CVS is rolling out a series of changes aimed at addressing the nation’s opioid crisis.
The retailer announced that it will impose a seven-day limit on the supply of opioids dispensed for certain prescriptions and will also limit the daily dosage of certain opioids.
When a patient receives an opioid prescription, pharmacists will first discuss the risks of dependence and answer any questions the patient may have.” (I)
“Google implemented new restrictions on advertising related to searches for addiction treatment after “misleading experiences” involving treatment centers, a company spokeswoman said. Credit Dominick
As drug addiction soars in the United States, a booming business of rehab centers has sprung up to treat the problem. And when drug addicts and their families search for help, they often turn to Google.
But prosecutors and health advocates have warned that many online searches are leading addicts to click on ads for rehab centers that are unfit to help them or, in some cases, endangering their lives.
This week, Google acknowledged the problem — and started restricting ads that come up when someone searches for addiction treatment on its site. “We found a number of misleading experiences among rehabilitation treatment centers that led to our decision,” Google spokeswoman Elisa Greene said in a statement on Thursday.” (J)
“State attorneys general battling the opioid crisis have turned their attention to health insurance companies and “unnecessary overprescription” of the class of painkillers. The letter urged payers to take action, though it didn’t acknowledge the many steps insurers have already taken.
The National Association of Attorneys General (NAAG) sent a letter America’s Health Insurance Plans, asking its members to “review payment and coverage policies and revise them, as needed, to encourage healthcare providers to choose alternatives to prescribing” opioids.
“When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective nonopioid alternatives, ranging from nonopioid medications such as nonsteroidal anti-inflammatory drugs to physical therapy, acupuncture, massage and chiropractic care,” the NAAG letter (PDF), signed by 37 state and territorial attorneys general, argued.” (K)
“A local hospital group has developed a program that helps patients get alternative treatments for chronic pain besides prescription opioids, helping the network decrease its opiate use by 20 percent since it started implementing the steps in 2013.
The opioid overdose crisis has been in part connected to over-prescription of high power painkillers, and the KetteringHealth Network said at a Monday press conference that its goal with its new program, called “Pause,” is to get providers and patients to pause and consider alternatives to prescriptions that patients may become addicted to.
As the region’s opioid crisis intensified through the first half of this year, Montgomery County hospital emergency departments received 2,565 overdose patients — more than any other Ohio county. In all, Ohio emergency departments treated 19,128 overdoses during the period, including 2,204 in Cuyahoga County, the state’s most populous.
The state also has guidelines for treatment of chronic pain. Ohio Mental Health & Addiction Services’ guidelines encourage providers to assess whether they are in compliance with prevailing standards of care. The guidelines also ask providers to look into non-opioid therapy options and avoid long term prescribing opioids.” (L)
“A new University of Michigan initiative aiming to address societal health problems will begin with the opioid crisis, President Mark Schlissel announced Tuesday, Oct. 3…..
Michigan health-care providers wrote 11 million prescriptions for opioid drugs in 2015 and another 11 million in 2016, compared to roughly 8 million prescriptions in 2009. That equates to about 1.1 prescriptions for every Michigan residents, according to the state’s drug monitoring system.
“When patients undergo surgery and get an opioid prescription, some achieve good pain control using the prescribed dose, but many others don’t. And some become addicted,” Schlissel said. “Most new chronic users receive their first opioid prescription for post-surgical care, and 6 percent of patients who have never had an opioid before will become dependent long after surgery. Some patients don’t take their full dose, meaning unused pills can end up in the wrong hands.”
Schlissel said the project will examine ways health professionals can predict how much pain medication someone will need, based on their individual genetic profile, physiological condition and social, environmental and lifestyle factors, tailoring how they help individual patients manage pain.” (M)
“Cigna says it won’t cover prescriptions for the brand OxyContin for most customers starting next year — it’ll be taken off group preferred commercial drug lists.
In 2016, Cigna laid out a three-year plan to cut down on opioid use among its customers by a quarter. It seems this move is an effort to help meet that goal.
There are a few caveats to this announcement: Cigna will still cover at least one oxycodone alternative, and people who use OxyContin for hospice or cancer care will have their prescriptions covered. The company also says it’ll consider approving OxyContin if a customer’s doctor deems it medically necessary.
Cigna is notifying patients with current OxyContin prescriptions and their doctors about the future change.
“While drug companies don’t control prescriptions, they can help influence patient and doctor conversations by educating people about their medications. The insights we obtain from the metrics in the new value-based contract will help us continue to evolve our opioid management strategies to assist our customers and their doctors,” Jon Maesner, Cigna’s chief pharmacy officer, said.” (N)
“Wisdom teeth surgery involves pliers, so there’s often some post-operative pain. For years, dentists have prescribed painkilling opioids, like percocet or vicodin for patients.
But with opioid abuse claiming lives in Colorado and across the country, oral surgeons and other health care providers are looking to alternatives. Lafayette oral surgeon Curt Hayes recently switched to FDA-approved local anesthetic Exparel, a non-opioid. When he injects it into his patient’s’ gums the area will stay numb and pain free for two to three days.
He can now generally remove wisdom teeth without using any narcotics for pain — so there’s no need to prescribe his patient a dozen or more pills.
“I’ve backed off to where I don’t give any narcotics whatsoever,” said Hayes. “I have people just using ibuprofen and then over-the-counter Tylenol, and that’s acceptable. And it takes care of the pain.”
Hayes followed the development of Exparel, also known by its generic name bupivacaine, in journals. Other doctors started using it for C-Sections. He started using it mainly for patients who had abused narcotics in the past, to avoid relapses. After seeing positive results, Hayes started making it an option for all his patients….
Colorado’s dental board is developing new best practices and the Colorado Dental Association is holding educational seminars. Dr. Brett Kessler, a dentist in Denver and past president of the state association, said across the board, medical providers are re-examining their role in the opioid crisis.
“It’s on every health care practitioner’s mind,” Kessler said. “Looking for alternatives to manage the pain is huge, and it’s a growing trend nationally.” “(O)
“How to help someone with an opioid problem
The state’s Next Level Recovery website suggests watching for these seven signs that you or someone you care about might have an opioid-use disorder:
• Needing higher doses of the opioid to get the same effect that a lower dose used to provide.
• Trying to quit more than once without having success.
• Thinking about getting high as soon as you wake up in the morning.
• Getting anxious or agitated within several hours of your last dose.
• Experiencing vomiting, diarrhea or nausea after quitting for a short period of time.
• Having less interest in activities you used to enjoy.
• Using opioids when driving or caring for children.” (P)
“In the state morgue here, in the industrial maze of a hospital basement, Dr. Thomas A. Andrew was slicing through the lung of a 36-year-old woman when white foam seeped out onto the autopsy table.
Foam in the lungs is a sign of acute intoxication caused by an opioid. So is a swollen brain, which she also had. But Dr. Andrew, the chief medical examiner of New Hampshire, would not be certain of the cause of death until he could rule out other causes, like a brain aneurysm or foul play, and until after the woman’s blood tests had come back….
After laboring here as the chief forensic pathologist for two decades, exploring the mysteries of the dead, he retired last month to explore the mysteries of the soul. In a sharp career turn, he is entering a seminary program to pursue a divinity degree, and ultimately plans to minister to young people to stay away from drugs.” (Q)
(A) Elizabeth Warren, Lisa Murkowski Push Trump To Declare Opioid Crisis A National Emergency, by By Paige Lavender, https://www.huffingtonpost.com/entry/warren-murkowski-opioids_us_59df88b9e4b00abf3646f4dc
(B) Chris Christie: Trump’s delay in declaring the opioid crisis a national emergency is ‘not good’, by Naomi Lim, http://www.washingtonexaminer.com/chris-christie-trumps-delay-in-declaring-the-opioid-crisis-a-national-emergency-is-not-good/article/2637108
(C) Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers, by KATIE THOMAS and CHARLES ORNSTEIN, https://www.nytimes.com/2017/09/17/health/opioid-painkillers-insurance-companies.html
(D) A Generation at Risk: Children at Center of America’s Opioid Crisis,by DANIEL A. MEDINA, KATE SNOW, ML FLYNN and ERIC SALZMAN, https://www.nbcnews.com/storyline/americas-heroin-epidemic/generation-risk-children-center-america-s-opioid-crisis-n806456
(E) Using Big Data Medical Analytics To Address The Opioid Crisis, John Kelley, https://www.forbes.com/sites/forbestechcouncil/2017/10/02/using-big-data-medical-analytics-to-address-the-opioid-crisis/#18c0e84c142c
(F) Opioid crisis: Researchers employ new method to track overdose victims, by Michelle Chavez, http://www.foxnews.com/health/2017/10/10/opioid-crisis-researchers-employ-new-method-to-track-overdose-victims.html
(G) Even in hospitals, opioids can cause harm, by Tom Avril, http://www.philly.com/philly/health/addiction/opioid-overdose-in-hospital-medication-error-narcan-20171016.html
(H) America’s 8-Step Program for Opioid Addiction, https://www.nytimes.com/2017/09/30/opinion/opioid-addiction-treatment-program.html?mcubz=0
(I) CVS is taking steps to address the nation’s opioid crisis, http://abc13.com/health/cvs-imposes-opioid-limits-to-address-nations-crisis/2441143/
(J) Google Sets Limits on Addiction Treatment Ads, Citing Safety, by By MICHAEL CORKERY, https://www.nytimes.com/2017/09/14/business/google-addiction-treatment-ads.html?_r=0
(K) State AGs push health insurers to rein in opioid prescriptions, fail to acknowledge they’re already doing so, by Gienna Shaw, http://www.fiercehealthcare.com/payer/how-do-health-insurance-companies-control-opioid-abuse
(L) Hospital program attempts to reduce opioid use in patients, Kaitlin Schroeder, http://www.daytondailynews.com/news/local/hospital-program-attempts-reduce-opioid-use-patients/m61zU9FMvhQL1mWzEZ1NxI/
(M) University of Michigan tackling opioid crisis in new health initiative, by Martin Slagter , http://www.mlive.com/news/ann-arbor/index.ssf/2017/10/university_of_michigan_tacklin.html
(N) A top health insurance company is joining the fight against the opioid epidemic., by Cristina Mutchler, http://www.wtmj.com/newsy/health-insurer-drops-oxycontin-coverage-to-fight-opioid-crisis
(O) Colorado Dentists And Other Docs Seek Opioid Alternatives As Crisis Worsens, by John Daley, http://www.cpr.org/news/story/colorado-dentists-and-other-docs-seek-opioid-alternatives-as-crisis-worsens
(P) How to help someone with an opioid problem, by Jenny Ung and Jennifer Morlan, https://www.usatoday.com/story/news/nation-now/2017/10/08/how-help-someone-opioid-problem/745046001/
(Q) As Overdose Deaths Pile Up, a Medical Examiner Quits the Morgue, by KATHARINE Q. SEELYE, https://www.nytimes.com/2017/10/07/us/drug-overdose-medical-examiner.html?_r=0
a day earlier, saying he could never support legislation “bailing out” insurance companies.
On Tuesday, Trump appeared to embrace the deal struck by Republican Senator Lamar Alexander and Democratic Senator Patty Murray as “a short-term solution so that we don’t have this very dangerous little period,” apparently referring to possible premium spikes in the wake of his recent decision to cut off subsidy payments to insurance companies.
But in a tweet on Wednesday he took a different tack on the bill, which would continue the cost-sharing subsidies that lower premiums for lower-income Americans, writing: “I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co’s who have made a fortune w/ O’Care.” (A)
“A proposal in the Senate to help stabilize Affordable Care Act marketplaces would ensure that subsidies paid to insurance companies benefit consumers rather than padding the companies’ profits.
A draft of the bill, obtained by NPR, requires health plans to offer the subsidies as one-time or monthly rebates to consumers or they will be repaid to the federal government. The subsidies, known as cost-sharing reduction payments, are designed to reimburse insurance companies for discounts they are required to offer their customers on copayments and deductibles. President Trump has criticized the payments as a “bailout” and said last week he would cut them off.” (B)
“Sens. Lamar Alexander and Patty Murray have reached a deal “in principle” to restore Affordable Care Act cost-sharing reduction payments for two years in exchange for more state flexibility in Obamacare.
One Senate aide said the plan would also restore just over $100 million in funding for Obamacare outreach, which is particularly critical since the Trump administration has slashed support for 2018 open enrollment, which begins on November 1.
An Alexander aide told CNN that Republicans would get a provision they wanted, a major change in how states measure the affordability of insurance under their waiver requests. This would allow states a lot more flexibility, but that final language was still being ironed out.
The deal would make it easier for states to obtain waivers to customize Obamacare rules to their needs. States have complained that applying for waivers is a long and complicated process. Alaska and Minnesota, for instance, have received permission to use federal funds for reinsurance programs that reduce premiums. This agreement would speed administration approval of the waivers and allow states to copy provisions in waivers that were already approved.
However, it does not actually loosen any of Obamacare’s regulations, which had been a key goal of the Republican effort to repeal the health reform law.
The agreement would also allow all Obamacare enrollees to sign up for so-called catastrophic plans, which have lower premiums but have higher deductibles. Right now, these so-called copper policies are only open to those under 30.
There are no guarantees that Republican leadership would bring such a plan to the floor without significant support from rank-and-file members. Getting a sizable number of co-sponsors will be key to the Murray and Alexander’s success. That work has yet to begin. “ (C)
“A bipartisan Senate deal that would extend critical ObamaCare payments to insurers for two years got the cold shoulder from Republicans on Tuesday, suggesting it faces a rocky path to become law.
The chairman of the conservative Republican Study Committee in the House dismissed the offering from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) as an affront to GOP promises to repeal President Obama’s signature legislation.
“Anything propping [ObamaCare] up is only saving what Republicans promised to dismantle,” said Rep. Mark Walker (R-N.C.), who leads a group of more than 150 conservatives.
Senate Majority Leader Mitch McConnell (R-Ky.) stopped short of promising to bring the bill to the floor, and while Sens. John McCain (R-Ariz.) and Susan Collins (R-Maine) offered some praise, not a single Senate GOP conservative offered strong public support for the compromise.
Senate Democrats, in contrast, hailed the deal, and pressed GOP leaders to quickly bring it to the floor.” (D)
Hospitals should see rising bad debt in 2018 as these co-pays/deductibles go unfunded
Without CSRs, insurers say, Obamacare patients will see costs jump 25% or more in 2018
The nation’s doctors and hospitals are bracing for an increase in unpaid medical bills after President Donald Trump’s decision on Friday to stop funding subsidies that low-income Americans use to pay their out-of-pocket costs.
Trump’s decision comes just before the beginning of open enrollment on Nov. 1 for subsidized individual coverage sold on public exchanges for 2018 under the Affordable Care Act. Cost-sharing reductions (CSRs) help purchasers of subsidized silver plans pay their co-payments and deductibles…
Trump’s move also comes with Americans, beyond just those in Obamacare plans, already seeing a jump in their out-of-pocket healthcare costs. Employee benefits consultancy Aon says out-of-pocket costs for workers at large employers will, for the first time in 2018, eclipse $2,500, and that trend has impacted providers.” (E)
“As a candidate, Donald Trump sold himself as a deal maker. As president, he’s governing more as a hostage taker.
Across an array of domestic and foreign challenges, Trump’s go-to move has become to create what amounts to a political hostage situation. He’s either terminating, or threatening to terminate, a series of domestic and international policies adopted by earlier administrations — and insisting that others grant him concessions to change his mind….
Trump’s expectation is that his threats will strengthen his leverage over whoever he’s negotiating against — whether Democrats in Congress, foreign governments, or both. But the early experience suggests that Trump’s actions more often may have the opposite effects: to isolate him, divide his allies, and harden opposition to his proposals.
Trump’s threats to undo major agreements have unquestionably heightened anxiety and created disruption for those he’s trying to pressure.
Just the possibility that Trump would end the cost-sharing payments, which reimburse insurance companies for limiting out-of-pocket health care costs for low income consumers, already forced insurers to preemptively raise premiums this year, adding more pressure on Obamacare markets. His move to actually stop the payments could make coverage unaffordable for many more of the uninsured and/or prompt insurance companies to flee more states under the ACA.” (F)
“Now, in reality, the Obama administration was highly selective in enforcing the Affordable Care Act as written. Here are just some examples of ways in which Obama simply ignored the Affordable Care Act and decided to do what he thought was best, regardless of the law:
The Obama administration decided not to enforce the law’s employer mandate until 2015, and then delayed its enforcement a second time.
After millions of Americans complained that their insurance plans had been canceled—contrary to Obama’s promise that “if you like your plan, you can keep your plan”—Obama declined to enforce aspects of the law that required those plans to shut down—until he was reelected.
The Obama administration decided—unilaterally—to waive Obamacare’s individual mandate, by granting a “hardship exemption” to anyone for whom Obamacare’s offerings were “unaffordable.”
The Affordable Care Act forced insurers to offer plans with reduced co-pays and deductibles for those with very low-incomes, but didn’t appropriate the cost-sharing subsidies needed to pay for them. Facing a rebellion from insurers, who were being forced to cover these individuals at a loss, the Obama administration decided to spend the money anyway, even though they had no legal authority to do so.” (G)
(A) Trump Backs Away From Bipartisan Senate Healthcare Bill, by Tim Ahmann, https://www.usnews.com/news/top-news/articles/2017-10-18/trump-backs-away-from-bipartisan-senate-healthcare-bill
(B) Draft Of Health Care Bill Addresses Trump Concerns About ‘Bailouts’ For Insurers, by Alison Kodjak, http://www.npr.org/2017/10/18/558546804/draft-of-health-care-bill-addresses-trump-concerns-about-bailouts-for-insurers
(C) Bipartisan senators reach small deal on health care, by Lauren Fox and Tami Luhby, http://www.cnn.com/2017/10/17/politics/health-care-csr-payments-deal-reached/index.html
(D) New health deal falls flat with GOP, by PETER SULLIVAN, http://thehill.com/policy/healthcare/355917-new-health-deal-falls-flat-with-gop
(E) Hospitals Brace For Unpaid Patient Bills After Trump Ends Obamacare Subsidies, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/15/hospitals-brace-for-unpaid-patient-bills-after-trump-ends-obamacare-subsidies/#f1ee9b251f8d
(F) How Donald Trump is negotiating like a hostage-taker, by Ronald Brownstein, http://www.cnn.com/2017/10/17/politics/donald-trump-negotiating-strategy/index.html
(G) Sorry Everbody, But Trump Hasn’t Instigated The Obamacare Apocalypse, by Avik Roy, https://www.forbes.com/sites/theapothecary/2017/10/14/sorry-everbody-but-trump-hasnt-instigated-the-obamacare-apocalypse/#219155ae7099
“In April 2016, at the height of the deadliest drug epidemic in U.S. history, Congress effectively stripped the Drug Enforcement Administration of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets…
A handful of members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills, according to an investigation by The Washington Post and “60 Minutes.” The DEA had opposed the effort for years.
The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns…
For years, some drug distributors were fined for repeatedly ignoring warnings from the DEA to shut down suspicious sales of hundreds of millions of pills, while they racked up billions of dollars in sales.
The new law makes it virtually impossible for the DEA to freeze suspicious narcotic shipments from the companies, according to internal agency and Justice Department documents and an independent assessment by the DEA’s chief administrative law judge in a soon-to-be-published law review article. That powerful tool had allowed the agency to immediately prevent drugs from reaching the street.” (A)
“President Donald Trump said Monday that “we’re going to be looking into” Rep. Tom Marino, the White House’s pick to be the nation’s next drug czar, after CBS’ “60 Minutes” and The Washington Post reported that the lawmaker championed a law that hobbled federal efforts to combat the abuse of opioids….
According to reporting by the Post and “60 Minutes,” Marino was the top lawmaker championing the Ensuring Patient Access and Effective Drug Enforcement Act, legislation that the news outlets said makes it essentially impossible for the Drug Enforcement Administration to freeze suspicious narcotics shipments from drug companies. The DEA had fought against the bill, while the pharmaceutical industry lobbied hard on its behalf.” (B)
“Republican members of Congress Tom Marino of Pennsylvania and Marsha Blackburn of Tennessee promoted the bill as a way to ensure that patients had access to the medication they needed…
“…. the argument that made the bill unanimously pass Congress was that “legitimate painkiller users were not getting their drugs in an efficient manner.”
“There’s nothing in the law that actually changes that at all,” Bernstein said during a conversation on “CBS This Morning.” “The evidence for that was actually sort of anecdotal. Whereas the evidence for the fact that these pills were ending up in the hands of dealers and users was quite substantial.”
Asked whether he feels as though these drug distributors are complicit in the opioid crisis, Bernstein responded, “Well, they certainly have been caught numerous times over, and over and over again, not reporting suspicious orders of these opioid pain pills from doctors and pharmacies.”” (C)
“Rep. Tom Marino, R-Pa., has withdrawn his name from consideration as America’s drug czar, President Trump said Tuesday. Marino is stepping back days after reports that legislation he sponsored hindered the Drug Enforcement Administration in its fight against the U.S. opioid crisis…
Marino was a main backer of the Ensuring Patient Access and Effective Drug Enforcement Act; among other things, the measure changed the standard for identifying dangers to local communities, from “imminent” threats to “immediate” threats. That change cramped the DEA’s authority to go after drug companies that didn’t report suspicious — and often very large — orders for narcotics.
Sen. Joe Manchin, D-W.Va., said he was “horrified” by the story, adding that he “cannot believe the last administration did not sound the alarm on how harmful that bill would be for our efforts to effectively fight the opioid epidemic.”
In a letter to the president, Manchin wrote about the ability of wholesale drug distributors to send millions of pills into small communities:
“As the report notes, one such company shipped 20 million doses of oxycodone and hydrocodone to pharmacies in West Virginia between 2007 and 2012. This included 11 million doses in one small county with only 25,000 people in the southern part of the state: Mingo County. As the number of pills in my state increased, so did the death toll in our communities, including Mingo County.”..
Manchin has co-sponsored legislation that would repeal the changes made by the 2016 law, along with Sen. Claire McCaskill, D-Mo., and Sen. Margaret Wood Hassan, D-N.H. “ (D)
“Mr. Marino’s withdrawal leaves three of the major federal agencies responsible for managing the opioid crisis—the White House drug-control office, the Department of Health and Human Services and the DEA—with no nominees to head them. Mr. Trump’s national opioid commission, led by New Jersey Gov. Chris Christie, is expected to release a final report with recommendations next month.
During his news conference, Mr. Trump said that he would likely make a “major announcement” on the “drug crisis” next week.” (E)
(A) THE DRUG INDUSTRY’S TRIUMPH OVER THE DEA, by Scott Higham and Lenny Bernstein, https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/?utm_term=.76234a485f43
(B) Trump: ‘Looking into’ Marino’s nomination as drug czar after report on opioid legislation, by LOUIS NELSON, http://www.politico.com/story/2017/10/16/trump-tom-marino-drug-czar-opioid-legislation-243827
(C) Washington Post reporter on how Congress may have fueled America’s opioid crisis, by LAUREN MELTZER, https://www.cbsnews.com/news/opioid-epidemic-60-minutes-washington-post-investigation-lenny-bernstein/
(D) Tom Marino, Trump’s Pick As Drug Czar, Withdraws After Damaging Opioid Report, by Bill Chappell, http://www.npr.org/sections/thetwo-way/2017/10/17/558276546/tom-marino-trumps-pick-as-drug-czar-withdraws-after-damaging-opioid-report
(E) Trump’s Pick for Drug Czar, Tom Marino, Withdraws Name from Consideration, by Peter Nicholas, https://www.wsj.com/articles/donald-trumps-pick-for-drug-czar-tom-marino-withdraws-name-from-consideration-1508244954
“In a move likely to roil America’s insurance markets, President Donald Trump will “immediately” halt payments to insurers under the Obama-era health care law he has been trying to persuade Congress to unravel for months….
“…. the White House said the government cannot legally continue to pay the so-called cost-sharing subsidies because they lack a formal authorization by Congress. Officials said a legal opinion from the Justice Department supports that conclusion…
Experts have warned that cutting off the money would lead to a double-digit spike in premiums, on top of increases insurers already planned for next year. That would deliver another blow to markets around the country already fragile from insurers exiting and costs rising. Insurers, hospitals, doctors’ groups, state officials and the U.S. Chamber of Commerce have urged the administration to keep paying…
Consumers who receive tax credits under the ACA to pay their premiums would be shielded from those premium increases. But millions of others buy individual health care policies without any financial assistance from the government and could face prohibitive increases. Taxpayers would end up spending more to subsidize premiums.” (B)
“ “Massive subsidy payments to their pet insurance companies have stopped,” Trump said in a Tweet early Friday morning, alluding to the support of Democrats in Congress for CSRs.
But the CSRs are a pass-through from the government through the insurer and directly to the patient. Thus, a single-digit rate increase becomes a rate increase of 20%-25% without the CSRs, insurers have warned for months now.
“These payments are not a bailout – they are passed from the federal government through health plans to medical providers to help lower costs for patients who see a doctor to treat their cancer or fill a prescription for a life-saving medication,” America’s Health Insurance Plans and the Blue Cross Blue Shield Association said in a joint statement Friday morning.
Most insurers, including Anthem, Oscar Health, Centene, Molina and Blue Cross and Blue Shield plans, will still make money if Americans buy their plans because customers will have to pay much higher rates thanks to Trump’s move. The end to CSRs, though, could prevent many from buying the policies in the first place or paying their out-of-pocket costs….” (C)
“The Trump administration is hinting that it will continue to enforce the ObamaCare mandate requiring Americans to have health insurance coverage. An administration document obtained by The Hill that accompanies an executive order signed by President Trump Thursday states that “only Congress can change the law” when it comes to the mandate.
“Will the Administration be enforcing the individual and employer mandates?” the question and answer document asks.
“While HHS has the ability to define a hardship exemption for the purpose of the individual mandate, the tax penalties are contained in the Internal Revenue Code and only Congress can change the law,” the document states in response, referring to the Department of Health and Human Services.
The statement leaves some room for creating more exemptions to enforcement of the mandate, noting that the administration can offer “hardship exemptions.” But it emphasizes that only Congress can change the law that mandates penalties for not having coverage…..” (D)
“The combined effect of cutting off the insurance payments and the executive order will be to destabilize the A.C.A.’s individual market, which is used by nine million people to buy health insurance. Younger and healthier people will be tempted to buy a skimpy short-term policy with low premiums and switch to a policy that complies with the A.C.A. only when they need medical care. Knowing that they will no longer receive cost-sharing payments and that Obamacare policies will tend to attract older and sicker people, insurers will probably jack up premiums or withdraw altogether in sparsely populated counties.
State governments, public interest groups and others will seek to prevent some of the damage from the order. There is some hope that they will be able to shape the regulations during the public comment period. If the final rules are still harmful, some groups will most likely file lawsuits….(E)
“White House Chief of Staff John Kelly told reporters that there probably won’t be a new Obamacare repeal bill until the spring and declined to join President Trump in attacking Senate Republican leadership…
“We probably won’t have a healthcare bill until the spring,” he said. “This was a way to take care of as many Americans as he could legally with an executive order.”…”Congress is designed to be extremely complicated, slow-moving part of our government,” he said. “I have nothing but respect for members of Congress and the staffs that work for them.” (F)
“In theory, precipitously ending the payments could lead to catastrophic market failures. Insurers set prices for their insurance this year, assuming the payments would continue to be made, and have no ability to raise them midyear to cover their losses. But, because the president has repeatedly signaled that the payments might cease and we are nearing the end of 2017, many plans set their prices for next year’s products assuming the subsidies would not be paid.
A few months ago, we called those increased prices an uncertainty tax. The uncertainty is gone now. But the conservative planning of the insurance industry means that many insurers can afford to keep offering insurance, even after the president cuts off the funding. Plans that priced for the threat will take a small haircut this year, but they can still make money, even without the payments, next year.” (G)
“Even before Mr. Trump’s decision, Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, were working on legislation to extend the subsidies, paired with other measures to offer states more flexibility regulating health plans offered under President Barack Obama’s health law.
But Republicans in Congress are divided. Some worry that ending the subsidies would hurt their constituents. Others are loath to do anything that could be seen as propping up the health law that they had promised to tear down.
For their part, Democrats are convinced that any blame for rising premiums and shrinking choices will fall on Republicans, who now control the White House and Congress. After spending the year trying to preserve the Affordable Care Act, Democrats did not appear ready on Friday to make major concessions.” (H)
“But there’s another question here, which is the electoral consequence. If health insurance gets worse, will people blame Barack Obama and the Democrats, or Donald Trump and the Republicans?” (I)
(A) Trump vows to rip apart Obamacare piece by piece, http://abcnews.go.com/WNT/video/trump-vows-rip-obamacare-piece-piece-50472671
(B) Trump to issue stop-payment order on health care subsidies, by ricardo alonso-zaldivar, http://abcnews.go.com/Health/wireStory/trump-halt-subsidies-health-insurers-50455624
(C) Trump’s Termination Of Obamacare Subsidies Hurts Patients, Not Insurers, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/13/trumps-end-to-subsidies-hurts-patients-not-insurers/#525cb1444c61
(D) Trump administration hints at enforcing ObamaCare mandate, BY PETER SULLIVAN, http://thehill.com/policy/healthcare/355144-trump-administration-hints-at-enforcing-obamacare-mandate
(E) Congress Can’t Let Mr. Trump Kill Obamacare on His Own, https://www.nytimes.com/2017/10/12/opinion/editorials/congress-cant-let-mr-trump-undo-obamacare-on-his-own.html?_r=0
(F) John Kelly: Obamacare repeal effort likely to return in spring, by Robert King, http://www.washingtonexaminer.com/john-kelly-obamacare-repeal-effort-likely-to-return-in-spring/article/2637332
(G) Trump Is Trying to Gut Obamacare. Here’s Why His Plan May Fail, by Margot Sanger-Katz, https://www.nytimes.com/2017/10/13/upshot/trump-is-telling-obamacare-insurers-he-doesnt-support-the-market.html
(H) End to Health Care Subsidies Puts Congress in a Tight Spot, By THOMAS KAPLAN and ROBERT PEAR, https://www.nytimes.com/2017/10/13/us/politics/trump-congress-obamacare-insurance-subsidies.html
(I) Trump’s Head-Scratching Health-Care Moves, by Jonathan Bernstein, https://www.bloomberg.com/view/articles/2017-10-13/trump-s-head-scratching-health-care-moves
“President Donald Trump signed an executive order Thursday morning intended to allow small businesses and potentially individuals to buy a long-disputed type of health insurance that skirts state regulations and Affordable Care Act protections.
The White House and allies portray the president’s move to expand access to “association health plans” as wielding administrative powers to accomplish what congressional Republicans have failed to achieve: tearing down the law’s insurance marketplaces and letting some Americans buy skimpier coverage at lower prices. The order is Trump’s biggest step to carry out a broad but ill-defined directive he issued his first night in office for agencies to lessen ACA regulations from the Obama administration…
According to White House and agency officials, , the most far-reaching element of the multi-prong order instructs a trio of Cabinet departments to rewrite federal rules for association health plans – a type of insurance in which small businesses of a similar type band together through an association to negotiate health benefits.
The order will expand the availability of short-term insurance policies, which offer limited benefits meant as a bridge for people between jobs or young adults no longer eligible for their parents’ health plans. The Obama administration ruled that short-term insurance may not last for more than three months; Trump will extend that to nearly a year.” (A)
“In an effort to allow employers to form groups and obtain coverage across state lines, the order directs the administration to consider expanding Association Health Plans (AHPs), which allow small businesses in a similar sector or trade to band together to negotiate health benefits with other states.
This is a controversial measure and some experts predict there could be legal challenges, but supporters say it would increase competition by allowing employers to find the states offering the cheapest plans. It could also give more leverage to small businesses to negotiate policies. Additionally, the order calls for a broader interpretation of the Employee Retirement Income Security Act (ERISA), a law that regulates group plans provided by employers.
While ObamaCare mandated that short-term insurance policies should not last for more than three months, Trump is looking to expand those plans. The order says these short-term limited duration insurance (STLDI) offerings typically cost one-third of the price of the cheapest ObamaCare plans, while featuring broad provider networks and coverage. These plans are also not subject to most ObamaCare requirements…
The administration’s order also directs the government to look into ways to expand the use of Health Reimbursement Arrangements, or tax-free accounts that allow employers to reimburse employees for medical expenses. This measure is intended to give Americans greater control over their finance and health care.” (B)
“Although Mr. Trump has been telegraphing his intentions for more than a week, Democrats and some state regulators are now greeting the move with increasing alarm, calling it another attempt to undermine President Barack Obama’s signature health care law. They warn that by relaxing standards for so-called association health plans, Mr. Trump would create low-cost insurance options for the healthy, driving up costs for the sick and destabilizing insurance marketplaces created under the Affordable Care Act.
“It would have a very negative impact on the markets,” said Mike Kreidler, the insurance commissioner in Washington State. “Our state is a poster child of what can go wrong. Association health plans often shun the bad risks and stay with the good risks.”
They also worry that the Trump administration intends to loosen restrictions on short-term health insurance plans that do not satisfy requirements of the Affordable Care Act.
“By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges,” said Topher Spiro, a vice president of the Center for American Progress, a liberal research and advocacy group. “For older, sicker people left behind in plans regulated under the Affordable Care Act, premiums could increase.”” (C)
“Critics, however, worry that the order may free these association health plans from several key Obamacare regulations and from state oversight, allowing them to sell plans with lower premiums but skimpier benefits. That could draw younger and healthier customers away from Obamacare and send premiums skyrocketing for sicker people left in the exchanges.” (D)
“If Donald Trump signs an executive order as early as this week allowing insurance companies to be able to sell health plans across state lines, it’s unlikely to have any takers willing to prop up medical provider network in new regions.
The trend in insurance is to narrow – not expand – networks of doctors and hospitals.
“Insurance companies have not been very interested because we are moving to these network based plans,” Sabrina Corlette, professor with the Center on Health Insurance Reforms at Georgetown University said last week during a Commonwealth Fund briefing. “Since the 1990s, health insurance has evolved and has been a network driven product.”
It’s unclear exactly what will be in Trump’s executive order, which he mentioned within days after the failure of the latest Republican attempt to replace and replace the Affordable Care Act.
Health insurance companies in some states can already sell health coverage across state lines, but it hasn’t worked in large part because plans haven’t wanted to spend the money contracting with more doctors and hospitals in areas they have no enrollees. Six states have enacted laws allowing health plan sales across state lines and “no state was known to actually offer or sell such policies,” National Conference of State Legislatures said in a new report last week.
“In the states that have tried to do this, there has been zero interest from carriers,” Georgetown’s Corlette, who is also the consumer representative to the National Association of Insurance Commissioners.” (E)
We’re Tracking the Ways Trump Is Scaling Back Obamacare. Here Are 11.,
By HAEYOUN PARK ,, https://www.nytimes.com/interactive/2017/10/12/us/trump-undermine-obamacare.html
TRUMP HEALTH CARE EXECUTIVE ORDER WILL DO WHAT GOP FAILED TO DO: LEAVE SICK AMERICANS WITHOUT HEALTH CARE, BY CHRISTIANNA SILVA
President Donald Trump’s executive order could take health care insurance away from millions of sick Americans, which was also a criticism of his earlier effort to repeal and replace the Affordable Care Act in Congress. The new plan would roll back some of Obamacare’s protections and coverage, but it could lower premiums for healthy Americans.
“Republicans in Congress should take President Donald Trump’s hint about working with Democrats on health care as motivation to follow through with their own promises, Mick Mulvaney, director of the White House Office of Management and Budget, said on Sunday’s “Meet The Press.”
Mulvaney’s comment comes on the heels of a Saturday morning tweet from Trump, stating: “I called Chuck Schumer yesterday to see if the Dems want to do a great HealthCare Bill. ObamaCare is badly broken, big premiums. Who knows!”
When asked what Republican lawmakers should take from that tease, Mulvaney responded, “Keep your promises.”
“The president wants to get something done,” he said. “He sees and understands what Obamacare is doing to folks back home, and he really doesn’t like it very much. So he’s looking for folks who will work with him to help change that. We had hoped it would be the Republicans in the Senate. They failed twice to do that. And can you blame the president then to sort of step back and say, ‘Okay, if my own party can’t deliver what I need, can I work with the other side?’ That’s not an unreasonable position.”” (F)
“Republican Sen. Ron Johnson said Sunday he believed Congress could reach an agreement on health care that includes continuing the funding of a key set of Obamacare subsidies to keep down insurance premiums.
The conservative Wisconsin senator said in an interview on CNN’s “State of the Union” that he understands some of his Republican colleagues are against funding the cost-sharing reduction — or CSR — payments. But he said the government should keep making the payments to prevent the cost of insurance skyrocketing.
President Trump has not committed to paying insurers the cost-sharing subsidies, which reduce deductibles and co-pays for low-income Obamacare enrollees. This has prompted many insurers to raise their premiums for 2018 to make up for the anticipated loss of the subsidies. The 2018 rates have already been finalized.
Johnson added that any such move to support continuing those payments would come with strings attached. “We should get something in return for that,” he said. For example, he said, Congress should make it so anyone has the option to purchase a “catastrophic plan” — insurance with relatively low premiums but high deductibles that provides fewer benefits. Johnson also said they should make health savings accounts more usable.” (G)
“Local and state groups that help with ObamaCare enrollment say they will likely have to reduce their services following funding cuts from the Trump administration.
Funding for the “navigator” groups, which provide outreach, education and enrollment assistance, was cut in half this year for being “ineffective,” Trump officials have said.
Now most of the navigator programs say they will have to limit their services this year, according to a new survey from the Kaiser Family Foundation (KFF).
Among programs that got reduced funding this year, 45 percent of statewide programs and two-thirds of regional programs said it is “somewhat or very likely” they will have to limit the territory their program will serve, according to the survey.
This could primarily impact consumers living in rural areas.
Some 55 percent of statewide navigator programs and 72 percent of regional programs expect to limit services to rural residents this year, KFF found. “ (H)
“New Jersey will lose more than 60 percent of the federal funding it expected to receive this year to help enroll vulnerable citizens in health insurance plans, a new report found, a change advocates fear will make it harder to reach those most in need of affordable care.
Officials at the federal Centers for Medicare and Medicaid Services announced more than $26 million in funding cuts in September that will impact the Affordable Care Act navigator programs in all but three states (Delaware, Kansas, and West Virginia); more than a dozen states lost at least half their funding.
New Jersey saw support drop to nearly $721,000 from the roughly $1.9 million received last year, according to a detailed analysis of these cuts released Wednesday by the nonprofit Kaiser Family Foundation. The money is distributed among five nonprofit programs that will see between 10 percent and 86 percent less funding this fall than they had to work with in 2016, the foundation determined.” (I)
What scares the members of Congress who for decades have collected hefty donations from the insurance and health-care industries and then used their positions of public trust to sustain and protect profiteering by those industries?
The threat of a single-payer “Medicare for All” health-care system.
By replacing the bureaucratic profiteers with an efficient system that would guarantee care for every American—and fair compensation for doctors and nurses—single payer would not merely make health care more accessible and more affordable. It would also make politics more honest and responsive to the will of the people.
House Speaker Paul Ryan has, through the campaign committees and political action committees that he guides, collected millions of dollars from Wall Street interests, insurance interests, pharmaceutical interests, private hospital and nursing home interests, and “health products” interests over the course of a political career that has seen him go to the mat, again and again, in defense of Wall Street interests, insurance interests, pharmaceutical interests, private hospital and nursing home interests, and “health products” interests.
So is it any surprise that Ryan keeps trying to “repeal and replace” the Affordable Care Act with measures that benefit his crony-capitalist campaign funders?
Single payer is a bad idea for senators whose political survival is based on banking checks from health-care profiteers. But it is a very good idea for America.” (J)
(A) Trump signs executive order to scale back Obamacare insurance rules, Amy Goldstein, http://www.chicagotribune.com/news/nationworld/politics/ct-trump-health-care-executive-order-20171012-story.html
(B) Trump’s health care order: What’s in it?, By Brittany De Lea, http://www.foxbusiness.com/politics/2017/10/12/trumps-health-care-order-whats-in-it.html
(C) Foiled in Congress, Trump Moves on His Own to Undermine Obamacare, By ROBERT PEAR and REED ABELSON, https://www.nytimes.com/2017/10/11/us/politics/trump-obamacare-executive-order.html?_r=0
(D) Trump begins Obamacare dismantling with executive order, by Tami Luhby and Kevin Liptak, http://www.cnn.com/2017/10/12/politics/trump-obamacare-executive-order/index.html
(E) How Narrow Networks Doom Trump’s Plan For Insurance Sales Across State Lines, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2017/10/08/how-narrow-networks-doom-trumps-insurance-sales-across-state-lines/#5b1ce52335f9
(F) Mulvaney on Trump’s Message to GOP: ‘Keep Your Promises’, by KAILANI KOENIG, https://www.nbcnews.com/politics/congress/mulvaney-pres-trump-s-message-gop-keep-your-promises-n808821
(G) Sen. Ron Johnson suggests compromise on health care, By Eli Watkins, http://www.cnn.com/2017/10/08/politics/ron-johnson-healthcare-cnntv/index.html
(H) ObamaCare enrollment groups likely to decrease services after Trump funding cuts, BY JESSIE HELLMANN, http://thehill.com/policy/healthcare/354879-obamacare-enrollment-groups-likely-to-decrease-services-after-trump-funding
(I) NJ LOSES FEDERAL FUNDING TO EXPAND ACA ENROLLMENT, by LILO H. STAINTON, http://www.njspotlight.com/stories/17/10/11/nj-loses-federal-funding-to-expand-aca-enrollment/
(J) Why Do Republicans (and Some Democrats) Vilify Single Payer?, by John Nichols, https://www.thenation.com/article/why-do-republicans-and-some-democrats-vilify-single-payer/