“The move to tuck the repeal of the so-called individual mandate into the tax overhaul is an attempt by Republicans to solve two problems: math and politics. Repealing the mandate, a longstanding Republican goal, would save hundreds of billions of dollars over the next decade. That would free up money that could be used to expand middle-class tax cuts or help pay for the overall cost of the bill, which can add no more than $1.5 trillion to the deficit over 10 years. It could also help secure the votes of the most conservative senators, enabling lawmakers to pass the bill along party lines.
If it becomes law, the repeal would save more than $300 billion over a decade but result in 13 million fewer Americans being covered by health insurance by the end of that period, according to the Congressional Budget Office. Republicans said on Tuesday that they would use the savings — which stem from reduced government spending to subsidize health coverage — to pay for an expansion of the middle-class tax cuts that lawmakers had proposed.
On Tuesday evening, the chairman of the Senate Finance Committee, Orrin G. Hatch, Republican of Utah, was expected to release an amendment that would add the repeal of the mandate to the Senate’s tax plan. On the House side, members of the Rules Committee met Tuesday evening, one day earlier than scheduled, to pave the way for a floor vote on Thursday. (A)

“Now it turns out that getting rid of the mandate could help Republicans as they tackle the difficult math of tax reform. According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade. A third of a trillion dollars can help pay for a lot of tax cuts. Which is why Senate Republicans, trying to find funding and keep their promise to dismantle Obamacare, are now vowing to add a mandate repeal to their tax bill. (B)

“President Donald Trump said Monday that he will nominate former pharmaceutical executive Alex Azar as secretary of the U.S. Health and Human Services Department….
Azar in February, during an interview on CNBC in February, said “The remarkable thing here is Obamacare is failing completely on its own terms.”
Speaking about what was then a prospective Republican Obamacare repeal-and-replacement bill, Azar said there was a consensus among Republicans and Democrats that the government should play a role in expanding insurance coverage and subsidizing its purchase by individuals. But he suggested that the way to do that was one other than Obamacare’s system.
And Azar was firm in his prediction that the GOP bill would become law within months.
“There will be a piece of legislation passes this year that is called ‘the repeal of Obamacare,’ ” Azar said. “I don’t know what’s going to be in the substance of it, but there will be a piece of legislation that says that.”
Azar was wrong about that. Republican leaders in Congress repeatedly fail to pass repeal-and-replace bills, despite controlling both the Senate and the House.
Azar has previously said he does not believe the expansion of Medicaid has been successful, saying he would have preferred to use government money through “private-sector vehicles” to deliver health care.” (C)

“Vice President Mike Pence is exerting growing influence over the American health care system, overseeing the appointments of more than a half-dozen allies and former aides to positions driving the White House’s health agenda.
On Monday, President Donald Trump nominated Alex Azar, a former Indianapolis-based drug executive and longtime Pence supporter as Health and Human Services secretary. If confirmed, Azar would join an Indiana brain trust that already includes Centers for Medicare & Medicaid Services Administrator Seema Verma and Surgeon General Jerome Adams. Two of Verma’s top deputies — Medicaid director Brian Neale and deputy chief of staff Brady Brookes — are former Pence hands as well, as is HHS’ top spokesman, Matt Lloyd.
Yet another Pence ally — Indiana state Sen. Jim Merritt — is in the running to be White House drug czar.
Pence’s sway with the policymakers controlling Obamacare, Medicare and Medicaid comes at a time when Trump and Congress continue to struggle with the repeal of the Affordable Care Act. But Pence and his cadre are driving a national agenda dominated by the kinds of conservative, anti-regulatory policies he embraced as Indiana governor.” (D)

“Azar has called Verma “one of the leaders in reinventing Medicaid.” He shares her view that the health care program for low-income Americans has to be put on a more “sustainable” financial footing, and states should be given more accountability and responsibility for running the joint federal/state program.
On the individual insurance market, the other major aspect of health care restructured by the Affordable Care Act, Azar has echoed the Trump administration’s view that the market is failing.
“Obamacare is going down right now,” Azar told Fox News in July. “It is an almost impossible market to do from an insurance perspective.””
He’s said the regulations need a “top-to-bottom comprehensive rewrite” to impose “as much free market, localized flexibility as humanly possible.” (E)

“There’s one set of eyes that President Trump’s appointees absolutely cannot ignore as they set about trying to reshape Obamacare and enact sweeping new changes to the government’s health-care programs.
They belong to Joe Grogan, director of health programs at the White House’s Office of Management and Budget.
You’ve probably never heard of Grogan — but you should know who he is. Grogan, perhaps more than any other member of Trump’s administration, holds the power to nix or give the nod to hundreds of regulations shaping how the federal government runs Medicare, Medicaid, the Affordable Care Act marketplaces, the FDA, the CDC and all the other sub-agencies contained within the sprawl of the Department of Health and Human Services.
Without Grogan’s assent, for example, the Centers for Medicare and Medicaid Services wouldn’t have been able to essentially wipe out steep and long-term drug discounts received by charity and rural hospitals. Last month’s rule change to the 340B program — viewed by many as rather gutsy on the part of CMS because it infuriated hospitals — had to get past Grogan’s desk at OMB, just like every other regulation change the administration wants to make.” (F)

“As Republican lawmakers worked on Monday toward a delicate compromise on a $1.5 trillion tax cut, President Trump threw himself back into the discussion, suggesting that Republicans could reduce taxes even further by repealing the Affordable Care Act’s mandate that most people have health insurance.
In recent weeks, Mr. Trump has called for including the repeal of the individual mandate in the tax bill. Doing so would save more than $300 billion over a decade and would allow Republicans to boast that they took a step forward in dismantling a law that continues to haunt them.” (G)

President Donald Trump remains intent on undoing the Obamacare individual mandate one way or another.
Encouraged by Trump, a group of congressional conservatives want to add repeal of the mandate to the GOP’s overhaul of the tax code. But other Republicans fear the toxic politics of Obamacare could jeopardize the tax fight, and so far have kept repeal language out of both Senate and House versions of the tax package.
That means it could be left to Trump to act unilaterally to neutralize what polls consistently show to be the most unpopular part of the Affordable Care Act.
Most legal observers believe the administration has the necessary authority to interpret the law and substantially weaken enforcement of the tax penalty levied on most Americans who fail to obtain coverage. The downside is that unraveling the mandate might ultimately make it harder for Republicans to follow through on their long-standing promise to repeal and replace Obamacare.
The White House has drafted an executive order to scrap the individual mandate, but is waiting to see if Congress opts to go first, multiple media outlets reported this week. House Ways and Means member Jim Renacci (R-Ohio) worked behind the scenes to add a repeal provision to tax legislation moving to the House floor, according to a source close to the talks.
The White House denies that any executive action is imminent.
“We are always looking for ways to provide relief from Obamacare,” said a spokesman in an email. “The longstanding issues with the mandate would be best resolved legislatively.” (H)

“After cutting funds for nonprofit groups that help people obtain health insurance under the Affordable Care Act, the Trump administration is encouraging the use of insurance agents and brokers who are often paid by insurers when they help people sign up.
The administration said in a recent bulletin that it was “increasing partnerships” with insurance agents and viewed them as “important stakeholders” in the federal marketplace, where consumers are now shopping for insurance. But some health policy experts warned that a shift from nonprofit groups, which are supposed to provide impartial information, to brokers and agents, who may receive commissions for the plans they recommend, carries risks for consumers.
“Insurance agents can educate consumers about the marketplace, and that is a good thing,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But I worry that they work on a commission and therefore have a financial incentive to steer consumers to particular products, which may or may not be in the consumer’s best interest.”” (I)

“Buried in almost every version of the Republican health care legislation this year was a little provision that would have enabled states to make a major change to their Medicaid programs, by requiring people to work if they’re going to get coverage. When those bills died, it appeared that Medicaid work requirements died with them.
But this week, Seema Verma, the head of the Centers for Medicaid & Medicare Services and a longtime supporter of work requirements, sent a strong message that work requirements are back on the table. In a speech to the country’s Medicaid directors, Verma lambasted the Obama administration’s approach to Medicaid, calling it a “tragic example of the soft bigotry of low expectations,” and argued that requiring Medicaid beneficiaries to work would improve the program.
The speech doesn’t result in any immediate policy changes, but CMS is reviewing at least seven waiver proposals from GOP-led states that would impose work requirements on their Medicaid populations. The details around each waiver vary and it’s unclear whether Verma, who helped design a work requirement policy in Indiana that was rejected by the Obama administration, will ask states to tweak their submissions or when she will approve the first waiver. But her speech this week was a clear sign that big changes are coming to Medicaid — even without any help from Congress.” (J)

“For years, red states have effectively been subsidizing part of health insurance for blue states.
By declining to expand their Medicaid programs as part of the Affordable Care Act, many of those states have passed up tens of billions of federal dollars they could have used to offer health coverage to more poor residents. That means that taxpayers in Texas are helping to fund treatment for patients with opioid addiction in Vermont, while Texans with opioid problems may have no such option.
If they did, they could collect billions of federal dollars to help them cover more low-income residents.
Now new estimates prepared by the consulting firm Avalere Health for The Upshot give a sense of just how much states are giving up. Texas could collect around $42 billion in Medicaid over a decade if it opted in, according to the Avalere analysis. Tennessee could pull in around 5 percent of its state budget next year. Altogether, Avalere estimates that the 18 states that have still not expanded Medicaid could give up more than $180 billion over the next 10 years.” (K)

(A) Senate Plans to End Obamacare Mandate in Revised Tax Proposal, by THOMAS KAPLAN and JIM TANKERSLEY, https://www.nytimes.com/2017/11/14/us/politics/tax-plan-senate-obamacare-individual-mandate-trump.html?_r=0
(B) Obamacare’s Insurance Mandate Is Unpopular. So Why Not Just Get Rid of It?, by Margot Sanger-Katz, https://www.nytimes.com/2017/11/14/upshot/obamacares-insurance-mandate-is-unpopular-so-why-not-just-get-rid-of-it.html
(C) Trump nominates former drug company executive Alex Azar as next Health and Human Services secretary, by Dan Mangan, https://www.cnbc.com/2017/11/13/trump-nominates-alex-azar-as-next-hhs-secretary.html
(D) Pence’s health care power play, by By ADAM CANCRYN, https://www.politico.com/story/2017/11/13/pence-health-care-azar-244859
(E) Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency, by Maureen Groppe, https://www.usatoday.com/story/news/2017/11/13/former-pharmaceutical-ceo-nominated-trump-head-department-health-and-human-services/858240001/
(F) The Health 202: The Trump appointee you’ve never heard of who’s reshaping health policy, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/11/13/the-health-202-the-trump-appointee-you-ve-never-heard-of-who-s-reshaping-health-policy/5a05e5fa30fb045a2e002f8e/?utm_term=.eabfd0d7cd19
(G) Trump Again Wades Into Tax Debate, Suggesting Repeal of Obamacare Mandate, by ALAN RAPPEPORT and THOMAS KAPLAN, https://www.nytimes.com/2017/11/13/us/politics/trump-taxes-obamacare-individual-mandate.html?_r=0
(H) Trump may use executive power to weaken Obamacare’s individual mandate, by Paul Demko, https://www.politico.com/story/2017/11/10/trump-executive-power-obamacare-mandate-244782
(I) Trump Administration Guiding Health Shoppers to Agents Paid by Insurers, by ROBERT PEAR, https://www.nytimes.com/2017/11/11/us/politics/obamacare-health-insurance-marketplace-agents.html?_r=0
(J) 5 things Trump did this week while you weren’t looking, by DANNY VINIK, https://www.politico.com/agenda/story/2017/11/10/trump-policy-immigration-cuba-regulation-000582
(K) What Red States Are Passing Up as Blue States Get Billions, by MARGOT SANGER-KATZ and KEVIN QUEALY, https://www.nytimes.com/2017/11/13/upshot/what-red-states-are-passing-up-as-blue-states-get-billions.html

In 2012 “The hospitals in Hudson County were the hardest hit by the superstorm, with Hoboken University Medical Center and Palisades Medical Center temporarily closed. While Jersey City Medical Center’s first floor was inundated, it moved patients to the second floor and remained open.
“Fortunately for us, we were able to maintain our generator,” Scott said, noting that the water came within inches of the generator fuel pumps. After the storm, the hospital raised the pumps eight feet above the high-water mark.
Jersey City Medical Center also is planning a series of raised embankments, automatic floodgates, and waterproofed walls to head off future disaster. The plans are inspired by Lourdes Medical Center in Binghamton, New York, which has used a similar system to keep water out.” (A)

“It’s been over a month since the last of Maria’s Category 4 hurricane-strength winds swept over Puerto Rico, but there is still damage yet to come…..Even with the aid of the federal government and the military, a health-care system facing multiple threats might not be able to protect some of the island’s most vulnerable citizens.
Many of those people are facing hard choices in Puerto Rico’s hospitals, which are at the front lines of disaster-relief efforts. While most hospitals have recovered from the storm’s early blows—which knocked most of them out of commission and left a few others dependant on generators—they have had to make do with shortages of power, water, and supplies; personnel crunches; and intensifying health-care needs from accidents and emergent diseases. Last week, a photograph posted by former Governor Alejandro García Padilla on Twitter showed doctors performing surgery by flashlight. From what physicians on the island tell me, such scenarios are common, as is physicians working double and triple shifts—circumstances made even more remarkable by the fact that the doctors themselves are victims of the storm.…. (B)

“…Over the weekend, the island’s power company fired a key contractor working to restore electrical service. The cancellation of the $300 million contract with Whitefish Energy, after the Federal Emergency Management Agency and other agencies expressed significant concerns about the deal, is expected to further delay the return of power throughout Puerto Rico.
The Puerto Rican government has prioritized getting power back to hospitals. Many smaller clinics and doctor’s offices, like other businesses on the island, still don’t have electricity.
Take, for instance, San Patricio Medflix, a diagnostic imaging center in greater San Juan. The center has state-of-the-art MRI, CT and nuclear medicine equipment.
Problems with a diesel generator recently led to the cancellation of 70 patients’ appointments, says Dr. Fernando Zalduondo Dubner, medical director of San Patricio Medflix in San Juan, Puerto Rico.
With Puerto Rico’s electric grid down since Sept. 20, the diesel generator, housed in a metal box the size of a shipping container, has been the sole source of power for his four-story medical complex.
Fuel has been a big problem. The generator consumers about 500 gallons of diesel a day…. (C)

“Waterborne illnesses are on the rise in Puerto Rico in the wake of Hurricane Maria — and health professionals fear the storm’s aftermath could unleash an epidemic on the devastated island.
The death toll from the storm rose to 51 on Tuesday, with the two latest victims dying of leptospirosis, a bacterial disease usually spread by contact with contaminated water, Puerto Rico Public Affairs Secretary Ramon Rosario told The Associated Press….
The disease is transmitted via exposure to the urine of infected animals, but humans are most commonly infected by coming in contact with contaminated water, especially through skin abrasions and the nose, mouth and eyes, according to World Health Organization…
The disease has a wide range of symptoms including high fever, headache, chills, vomiting and diarrhea, but some may have no symptoms at all, according to the CDC. Leptospirosis is treated with antibiotics, but without treatment it can lead to kidney damage, meningitis, liver failure and death, according to the CDC.” (D)

“Students and faculty from Ponce Health Sciences University (PHSU) in Ponce, Puerto Rico have been the sole providers of aid for residents in southern and central Puerto Rico who hadn’t received assistance since Hurricane Maria landed five weeks ago. Since the crisis began, the students/faculty have provided medical and psychological support services – and delivering privately donated goods and supplies – to the residents, most of whom lost their homes and all of their possessions in the hurricane.
“Every day, PHSU students, doctors, psychologists, public health professionals, staff, and community volunteers have been tirelessly delivering privately donated medicine, water, and food – and providing critical care medical attention – to our neighbors in rural mountain towns,” says Dr. David Lenihan, CEO of PHSU. “They’re clearing roads, wading through waterways, and going door-to-door to offer their help. In many cases, they’ve been the first responders who have made contact with, and offered assistance to, these remote areas since Maria made impact.”
PHSU restored operations and classes on October 9, and is one of only a few universities in Puerto Rico that have reopened since Maria hit. (E)

“We cannot weaken the EPA as hurricanes are growing worse…
When hurricanes hit, EPA’s emergency response staff, scientists and engineers are essential to keeping people safe. The agency helps prevent and monitors toxic releases and chemical spills from industrial facilities and Superfund sites, and helps inform the public about any local environmental dangers. EPA also helps local communities protect drinking and wastewater systems from sewage leaks and works to get them working again….
The situation in Puerto Rico and the U.S. Virgin Islands is much more severe. Millions of our fellow Americans do not have electricity, reliable clean drinking water or functioning sewage treatment. St. John has not had electricity since early September. On St. Thomas, the street lights don’t work, the smell of diesel generators lingers in the air and if you are indoors you often smell mold.
Keeping up with these kinds of challenges is hard enough for the EPA. But remarkably, the Trump administration and its allies have been working to cut funding for many of the EPA’s most important disaster-relief programs.” (F)

“Five years after Hurricane Sandy struck on Oct. 29, 2012, much of the region’s inundated infrastructure has been repaired and some of it has been improved. But most of the big plans to stormproof New York City remain just that: plans. And throughout the planning, the city has continued to advance toward the water, with glass high-rises stretching across the riverfront in Queens, Brooklyn and the Far West Side of Manhattan.
“Each year we don’t get a hurricane here we know we’ve dodged a bullet,” said Robert Freudenberg, the vice president for energy and environment at the Regional Plan Association, an urban research group. “We’re racing the clock still to try and prepare for another storm like Sandy.”…
A bright flash that could be seen from Brooklyn signaled the failure of a substation on the site and heralded the long blackout that began minutes later. More than seven million gallons of salt water poured into the Canarsie Tunnel, which carries L trains under the East River. Twelve blocks north, the sprawling Bellevue Hospital Center complex, New Yorks’ flagship public hospital, had to be evacuated for the first time because it had no power, elevator service or drinking water….
At Bellevue, a wall will be built behind the hospital as part of a flood barrier along the East River. “We would really rather shelter in place than evacuate,” said Roslyn Weinstein, a vice president for operations for NYC Health & Hospitals, the city’s public health system…
After Sandy, NYC Health & Hospitals was awarded $1.7 billion in federal aid to repair and improve three of its 11 public hospitals — Bellevue, Coney Island and Metropolitan in Manhattan — and a skilled nursing center on Roosevelt Island. Since then, electrical systems and generators have been moved out of basements and elevators and loading docks protected with waterproof panels.
Near Bellevue, NYU Langone Medical Center, which had to evacuate 300 patients, got $1.1 billion in federal aid. But the privately run hospital refused to say how it has spent that money, making it difficult to assess if the hospital is any better prepared today.” (G)

‘After every natural calamity, American politicians make big promises. They say: We will rebuild. We will not be defeated. Never again will we be caught unprepared.
But they rarely tackle the toughest obstacles. The hard truth, scientists say, is that climate change will increasingly require moving — not just rebuilding — entire neighborhoods, reshaping cities, even abandoning coastlines.
Resettling neighborhoods, making certain places off-limits to development, creating dikes and reservoirs is difficult, both financially and politically. It takes longer than most election cycles. Memories fade. Inertia sets in. Residents just want to get their lives back to normal. Politicians want votes, not trouble.
After Hurricane Katrina in 2005, New Orleans, for better and worse, used its cataclysm as an opportunity to reboot, not just fixing levees but overhauling public schools, hospitals and many neighborhoods. It was a wrenching process….”
“Three 500-year floods in three years means either we’re free and clear for the next 1,500 years,”… “or something has seriously changed.” (H)

“Hurricane Sandy “filled up Hoboken like a bathtub,” the mayor of that New Jersey city told reporter Eric Jaffe. The storm flooded 1,700 homes, knocked out the power grid and did $100 million worth of local damage….
Planners envision a combination of “hard” and “soft” infrastructure: “Hard” flood walls will protect high-risk sites along the riverfront. Meanwhile, a “soft” system of parks, green roofs and terraced wetlands will act like sponges, soaking up water long enough to keep the sewer system from being overwhelmed; remaining runoff will be held in a combined park/water-storage site until the storm passes, when pumps will return floodwater back into the river.” (I)

“ “This project serves as a model for how to address threats from storm surge in urban areas,’’ said Department of Environmental Protection Commissioner Bob Martin. His agency collaborated with the city, HUD, and the state Department of Community Affairs in developing the project.
The proposed system will utilize natural higher ground to maximize protection and will be designed to blend in seamlessly with the urban streetscape. It will provide protection for critical infrastructure such as the North Hudson Sewerage Authority, as well as public-safety facilities and three fire stations and a hospital.
The project calls for construction of a flood-resistant structure stretching from 19th Street in Weehawken and extending south to Hoboken, slightly inland from the river. An additional flood-resistant structure will be built along the southern end of Hoboken.” (J)

(A) NJ HOSPITAL OFFICIALS BEGIN PLANNING, BUILDING FOR THE NEXT SANDY, by ANDREW KITCHENMAN, http://www.njspotlight.com/stories/13/02/20/hospital-officials-begin-planning-building-for-the-next-sandy/
(B) Puerto Rico’s Dire Health-Care Crisis, by VANN R. NEWKIRK II, https://www.citylab.com/environment/2017/10/puerto-ricos-dire-health-care-crisis/544361/
(C) Lingering Power Outage In Puerto Rico Strains Health Care System, by JASON BEAUBIEN, http://www.npr.org/sections/health-shots/2017/10/30/560853587/lingering-power-outage-in-puerto-rico-strains-health-care-system
(D) Puerto Ricans at Risk of Waterborne Disease Outbreaks in Wake of Hurricane Maria, by DANIELLA SILVA, https://www.nbcnews.com/storyline/puerto-rico-crisis/puerto-ricans-risk-waterborne-disease-outbreaks-wake-hurricane-maria-n814461
(E) PHSU Medical Students/Faculty Have Been Sole Providers of Aid to Rural Towns in Southern Puerto Rico, https://www.prunderground.com/phsu-medical-studentsfaculty-have-been-sole-providers-of-aid-to-rural-towns-in-southern-puerto-rico/00108038/
(F) We cannot weaken the EPA as hurricanes are growing worse, by JUDITH ENCK, http://thehill.com/opinion/energy-environment/357388-we-cannot-weaken-the-epa-as-hurricanes-are-growing-worse
(G) Five Years After Sandy, by PATRICK McGEEHAN and WINNIE HU, https://www.nytimes.com/2017/10/29/nyregion/five-years-after-sandy-are-we-better-prepared.html
(H) Lessons From Hurricane Harvey: Houston’s Struggle Is America’s Tale, by MICHAEL KIMMELMAN, https://www.nytimes.com/interactive/2017/11/11/climate/houston-flooding-climate.html?_r=0
(I) After Hurricane Sandy, Hoboken works on plan to avoid future flood damage, by Nancy Szokan, https://www.washingtonpost.com/national/health-science/after-hurricane-sandy-hoboken-works-on-plan-to-avoid-future-flood-damage/2014/12/12/4ec919b6-7a44-11e4-b821-503cc7efed9e_story.html?utm_term=.3900e3b6794e
(J) Feds to Fund Massive Flood-Control Project for Hoboken, Nearby Towns, by Tom Johnson, https://www.washingtonpost.com/national/health-science/after-hurricane-sandy-hoboken-works-on-plan-to-avoid-future-flood-damage/2014/12/12/4ec919b6-7a44-11e4-b821-503cc7efed9e_story.html?utm_term=.3900e3b6794e

“And there’s no Obama-era policy that he (President Trump) has fought harder to kill than the former President’s signature piece of legislation, Obamacare. After countless failed attempts at killing the bill through legislative means, Trump decided he’d try to kill it by starving it. Its marketing budget? Yeah that went bye-bye. The idea was that if fewer people knew about the enrollment period, then fewer people would sign up for the service, and therefore the pools wouldn’t be full of enough healthy people, who won’t use their coverage much, to offset the cost of the sick people, who will have to use it constantly. It’s a plan that is equal parts devious and terrifying. Which is why it delights me to tell you that it doesn’t seem to be working.
According to The Hill, Obamacare signups during the first few days of enrollment have set new records and have surprised many in the industry.
The surge in sign-ups, which was confirmed by an administration official, comes despite fears from Democrats that enrollment would fall off due to the Trump administration’s cutbacks in outreach and advertising.
On the first day of enrollment alone, Nov. 1, one source close to the process told The Hill that more than 200,000 people selected a plan for 2018, compared with about 100,000 last year. More than 1 million people visited healthcare.gov that day, compared to about 750,000 last year, the source said.” (A)

Among Donald Trump’s more pernicious and oft-repeated lies is that the Affordable Care Act (ACA) is imploding. It isn’t. But to the extent that problems are mounting, they are largely his doing. In March, the nonpartisan Congressional Budget Office (CBO) concluded that “in most areas,” Obamacare’s exchanges were stabilizing, and that most enrollees who received subsidies wouldn’t see their premiums increase significantly. Six months later, the CBO issued another report that, according to CNN, named “several policies the White House is pushing” that will lead “to rising premiums and decreased enrollment in individual insurance markets over the next year.”…
Trump seems to think he knows what he’s up to. He has said on multiple occasions that, as premiums spike and enrollment falls, congressional Democrats will be forced to come to him with hats in hand to negotiate some sort of replacement for Obama’s signature law. That’s a bad misreading of public opinion, which tends to hold the party in the White House responsible for virtually everything. Indeed, a Kaiser poll conducted in August found that 60 percent of respondents think Trump and Republicans would be “responsible for any problems with the ACA going forward,” compared with just 28 percent who said the same of Obama and Democrats.” (B)

“Choosing health insurance can be a hassle under the best of circumstances. But if you get your coverage from an Obamacare health insurance exchange, it’s more important than ever to shop around this year.
There are a lot of changes in store for consumers who buy coverage from HealthCare.gov or state-run health insurance exchanges, such as Covered California and New York State of Health. Premiums will be higher for most people, as usual.
And actions taken by President Donald Trump have driven prices even higher than they would’ve been ― and have made the shopping process more complicated, even for existing exchange customers.
Those actions will make health insurance too expensive for many consumers. But it will also mean better insurance for the same price for others ― or skimpier insurance that could even be free. That may seem strange, and that’s because it is strange, and complicated, which highlights how crucial it is for shoppers to do their homework this year.
Long story short: People who signed up for mid-range “Silver” plans in the past will need to shop around because it might be a worse deal now. A consumer might assume that a Bronze plan is the least expensive, Gold and Platinum are the most costly and Silver is in the middle, and that the generosity of the benefits matches the price. That’s how the law had intended it to work, but it’s not necessarily the case anymore.
In one Los Angeles ZIP code, for example, a 40-year-old could pay $352.59 a month for an unsubsidized Gold plan with zero annual deductible, which is just $13.35 more than a Silver plan from the same health insurance company that comes with a $2,500 deductible. The lowest-cost unsubsidized Bronze plan in that part of the city costs $263.67 and has a $6,300 deductible.” (C)

“It’s time to select a health insurance plan for 2018! Whether we get covered through an employer or the Affordable Care Act exchanges, we’ll be told to carefully review our options to find a plan that will give us the best coverage for the least amount of money.
We will be told we need to shop.
“I encourage you to shop around,” Senator Jeanne Shaheen, Democrat of New Hampshire, told her Facebook followers who are choosing plans from the A.C.A. marketplaces. The human resources giant Mercer wrote last year, “This open enrollment, think of employees as shoppers.” The American Diabetes Association, the American Institute of Architects, the Robert Wood Johnson Foundation and Aetna all use the terms in their literature or on their websites.
Make it stop!
This is not shopping. Shopping is a fun activity, like choosing a pie from the bakery or picking out cereal at the supermarket. The farthest thing from “shopping” is the arduous annual ritual of reviewing the complex and all but impossible to decipher health insurance options.
That’s partly because insurers do their best to make the experience as miserable as possible. Many of them offer up less-than-accurate lists of providers and participating institutions. They reserve the right to deny you coverage of a service, and you won’t know if they have until the day you need it — and maybe after the fact. Prospectuses are complex, and few of us fully understand them. Only 9 percent of Americans can properly define all four of these rather vital phrases: health plan premium, health plan deductible, out-of-pocket maximum and coinsurance, according a survey recently released by United Healthcare.” (D)

“Rep. Kevin Brady, R-Texas, and Sen. Orrin Hatch, R-Utah, on Thursday introduced bills that would temporarily suspend the individual mandate under Obamacare, and fund the cost-sharing reduction payments President Trump said he would nix through 2019.
CBS News first obtained the text of Brady’s bill. (Here is the text of the bill as of 7:47 a.m. Wednesday.) Brady is the chairman of the House Ways and Means Committee, and Hatch is the chairman of the Senate Finance Committee
The Healthcare Market Certainty and Mandate Relief Act of 2017 places a moratorium on the individual mandate requiring Americans to have insurance from after December 31, 2016 until January 1, 2022, and retroactively nullifies the employer mandate from December 31, 2014, until Jan. 1, 2018.
The legislation also directs the federal government to fund cost-sharing reduction payments for the next two years. Last month, Mr. Trump abruptly announced he would end the cost-sharing reduction payments, which are payments the federal government makes to insurers under Obamacare to keep health costs low for low-to-middle-income families. The legislation, however, prohibits such payments to be given to an issuer of a health plan that includes abortion coverage.
The legislation also increases the maximum contribution limit for health savings accounts.” (E)

“President Trump on Wednesday suggested using the GOP tax bill to repeal ObamaCare’s individual mandate.
“Wouldn’t it be great to Repeal the very unfair and unpopular Individual Mandate in ObamaCare and use those savings for further Tax Cuts,” Trump tweeted.
The idea is being pushed by Sen. Tom Cotton (R-Ark.) and also has the backing of House Freedom Caucus Chairman Mark Meadows (R-N.C.).
Meadows said Wednesday he supports repealing the mandate in tax reform and thinks “ultimately” it will be included because he is going to push for it. He said he has been talking to Cotton about it.
A Cotton spokeswoman told The Hill that Cotton and Trump spoke by phone about the idea over the weekend and “the President indicated his strong support.” (F)

“President Donald Trump and Republican congressional leaders falsely claim that Obamacare, aka the Affordable Care Act, is “exploding” or in a “death spiral. To be sure, the health care law’s marketplaces – where people who lack job-based health insurance, are too young for Medicare and aren’t poor enough for Medicaid can buy comprehensive health insurance – have been Obamacare’s political Achilles heel. They don’t ensure that everyone who liked the health plan they had before the Affordable Care Act would be able to keep it or find a comparable plan in the marketplaces.
But a large and rising majority of enrollees are satisfied with their coverage.
And contrary to critics’ claims, the marketplaces are functioning and, as my Center on Budget and Policy Priorities’ colleagues Aviva Aron-Dine and Tara Straw explain, they’ll continue to provide affordable comprehensive coverage to millions of Americans, despite Trump administration sabotage that has driven up the “sticker price” of 2018 exchange premiums and will likely depress sign-ups in the open enrollment period that began this week.
Critics who focus on the sticker price ignore two key facts. First, most marketplace consumers are protected from rate hikes because they qualify for premium tax credits that help them pay for health insurance and that rise when premiums rise. Second, lower-income marketplace consumers are further protected by the health care law’s limits on how much of their income they will have to pay for deductibles and co-payments.
Insurance companies will participate in the marketplaces if they think they can make money based on the premiums they collect and the likely covered expenses of their policyholders. Obamacare’s individual mandate, which requires people to have insurance or pay a penalty, is there to increase marketplace enrollment and provide greater stability for insurers.” (G)

(A) Despite Donald Trump’s Best Efforts, Obamacare Signups Are Setting New Records This Year, by JACK MOORE, https://www.gq.com/story/obamacare-signups
(B) Everything Trump Is Doing to Sabotage the Affordable Care Act, by Joshua Holland, https://www.thenation.com/article/everything-trump-is-doing-to-sabotage-the-affordable-care-act/
(C) Under Trump, Obamacare Shopping Is Even More Confusing. We’re Here To Help, by Jeffrey Young, https://www.huffingtonpost.com/entry/trump-obamacare-shopping-confusion_us_59de8645e4b0fdad73b1d75e
(D) Choosing a Health Insurance Plan Is Not ‘Shopping’, by HELAINE OLENNOV. 2, 2017, https://www.nytimes.com/2017/11/02/opinion/health-insurance-shopping-obamacare.html?_r=0
(E) New GOP bill would halt Obamacare individual mandate, restore subsidy payments, https://www.cbsnews.com/news/here-is-kevin-bradys-bill-to-halt-individual-mandate-restore-subsidy-payments/
(F) Trump suggests repealing ObamaCare mandate in tax bill, by NATHANIEL WEIXEL, http://thehill.com/policy/healthcare/358201-trump-suggests-repealing-obamacare-mandate-in-tax-bill
(G) Obamacare Isn’t Exploding, by Chad Stone, https://www.usnews.com/news/economy/articles/2017-11-03/obamacare-isnt-exploding-despite-donald-trumps-sabotage-on-premiums

“For a year and a half — and more urgently for much of the last month — I have warned of the growing economic, social and political power held by the five largest American tech companies: Apple, Amazon, Google, Facebook and Microsoft.
Because these companies control the world’s most important tech platforms, from smartphones to app stores to the map of our social relationships, their power is growing closer to that of governments than of mere corporations….” (A)

“If there is to be a health-care revolution, it will create winners and losers. Andy Richards, an investor in digital health, argues that three groups are fighting a war for control of the “health-care value chain”.
One group comprises “traditional innovators”—pharmaceutical firms, hospitals and medical-technology companies such as GE Healthcare, Siemens, Medtronic and Philips. A second category is made up of “incumbent players”, which include health insurers, pharmacy-benefit managers (which buy drugs in bulk), and as single-payer health-care systems such as Britain’s NHS. The third group are the technology “insurgents”, including Google, Apple, Amazon and a host of hungry entrepreneurs that are creating apps, predictive-diagnostics systems and new devices. These firms may well profit most handsomely from the shift to digital….
Large hospitals, some of which count as both incumbents and traditional innovators, will also be affected. The rise of telemedicine, predictive analytics and earlier diagnoses of illnesses are expected to reduce admissions, particularly of the emergency kind that are most lucrative in commercial systems. The sickest patients can be targeted by specialist services, such as Evolution Health, a firm in Texas that cares for 2m of the most-ill patients across 15 states. It claims to be able to reduce the use of emergency rooms by a fifth, and inpatient stays in hospitals by two-fifths.” (B)

“Why are Google, Apple and others so keen on health care? How are these companies altering the healthcare space? Moreover, what does the future relationship between these players and health care look like? Here is all you need to know about the love affair between tech companies and health care:
Why the Sudden Interest?…Here are a few reasons why an increasing number of tech companies are breaking into the healthcare sector:
Disruption: Health care has always been, and still is, a sensitive and hugely complex universe. This industry is begging for innovative solutions in the marketplace that can make health care easier to navigate—for both patients and providers. As Intel general manager Michael Jackson says, “The opportunity exists because of disruption. There are fewer industries being disrupted more right now than health care.”
Talking about business opportunities in health care, Unity Stoakes, founder of StartUp Health, says, “The companies that are best placed to take advantage of these changes are those that really understand consumers.”
Who knows consumers better than Apple, Nokia, Google and Samsung do?
Affordable Care Act: Obamacare has given an impetus to data-driven medicine. In fact, the Affordable Care Act requires that data on cost and quality should be made freely available. The focus on big data, as well as consumers’ growing comfort with tracking their daily habits, has cleared the way for the introduction of wearable technology, mobile apps and other high-tech digital applications.” (C)

“So what do we get for these extravagant private and public costs? A system where it takes weeks to see a doctor face-to-face, where more than 6,500 locales are officially deemed to have too few medical professionals to meet patients’ needs, and where U.S. health outcomes are consistently mediocre compared with those of many of our developed-nation peers (and even some of the less developed ones).
This status quo is ripe for disruption. And while true reform will require all the relevant parties—government, industry, and health care consumers themselves—to make major adjustments, an insurgent group of digital health companies is doing its best to drag American medicine into the 21st century kicking and screaming.
That means superseding physical constraints like having an actual hospital by harnessing the power of mobile technology, making the act of taking your medicine less of a hassle, and peering into our very biological building blocks to wage war on the most intractable maladies….
Welcome to the digital health revolution.” (D)

“The prospect of the giant Internet retailer entering the business is beginning to cause far-reaching reverberations for a range of companies, roiling the shares of drugstore chains, drug distributors and pharmacy-benefit managers, and potentially precipitating one of the biggest corporate merger deals this year.
On Thursday, the pressure was plain to see. A report that Amazon had received pharmacy-wholesaler licenses in a dozen states triggered a fast and steep selloff that wounded the likes of McKesson Corp., AmerisourceBergen Corp. and Cardinal Health Inc….
Executives in the drug industry say that Amazon could use its expansive online reach and its logistical muscle to threaten companies that ship and sell medicines to consumers and cut pricing deals with drug makers.
“Size and scale-wise, they can disrupt anywhere they want to disrupt,” said Chip Davis, president of the Association for Accessible Medicines, a trade group for generic medication, in an interview Thursday.” (E)

“Drugstore operator CVS is in talks to buy health insurer Aetna for a proposed $200 per share or more, sources familiar said. The $66 billion or greater deal would be the largest ever in health insurance history, according to an analysis of Thomson Reuters data….
“They needed to defend the business from encroachment by Amazon,” RBC Capital Markets analyst George Hill told CNBC. “Amazon’s ability to impact the business over the near to mid term is low, but the ability to impact the stock is high.”
CVS would lose the ability to control its own destiny if it didn’t do something, Hill added. “This could be $260 billion in revenue [in 2019].”…
CVS has already been trying to establish greater control in its corner of the health care industry. In 2007, the company acquired Caremark pharmacy benefit manager, which has more than 75 million plan members.” (F)

“Apple appears to be preparing a major move into the health care industry, expanding from its platform of fitness and clinical trial enrollment apps into an area that could include FDA-regulated sensors, advanced clinical decision support and even electronic health records.
The tech giant is cementing partnerships with big health systems and hiring scores of health care professionals. While the company is keeping mum about its plans, techie fans hope Apple will become the agent of transformation that makes patients, rather than providers or EHR vendors, the guardians of health data.” (G)

“Now Microsoft is joining the ranks of tech companies working to take on healthcare’s thorniest issues with its ambitious Healthcare NExT initiative. Launched this week, the program aims to leverage Microsoft tools like the cloud and artificial intelligence to solve a slew of issues in the health system.
It’s a departure from the company’s previous healthcare projects, which have focused on data-based patient programs like Microsoft Health.
The new initiative will set up partnerships between Microsoft’s AI and Research organization and players in the healthcare industry, starting with a huge collaboration with the University of Pittsburgh Medical Center.
The idea is that Microsoft’s research and technology expertise will work with UPMC’s product development experts to build tech solutions that are shaped by the needs they are serving. This kind of synergy between the realities of everyday healthcare and the products designed to solve them has long been a stumbling block in healthcare tech initiatives.” (H)

“Wal-Mart Stores and Quest Diagnostics announced a partnership Monday that will bring Quest’s laboratory testing services to 15 Walmart locations in Florida and Texas by the end of the year.
The centers will initially provide testing services, but they may expand to include other “basic” healthcare services over time, the companies said.
“By providing laboratory testing and healthcare services where people also shop, we will make it easier for Walmart customers and their associates to get the quality diagnostic insights they need in convenient locations,” Steve Rusckowski, Quest Diagnostics’ CEO, said in a statement.
George Riedl, president of Walmart Health and Wellness, described Walmart as a “one-stop shop” for everyday health and wellness needs.
The partnership signals Walmart’s continued expansion in the healthcare space and a comprehensive patient-centered focus on healthcare delivery that strives to keep broader populations healthy. The company expanded its efforts to place retail clinics at its stores in 2014 through a collaboration with QuadMed, with a focus on preventive care and management of chronic conditions—some of the biggest drivers of rising healthcare costs.” (I)

“Google announced expanded partnerships with three blue-chip academic medical centers this past week, where bioinformaticians will explore how its machine learning technology can be deployed in clinical settings to mine EHR data for improved outcomes.
“Machine learning is mature enough to start accurately predicting medical events – such as whether patients will be hospitalized, how long they will stay, and whether their health is deteriorating despite treatment for conditions such as urinary tract infections, pneumonia, or heart failure,” said Google Brain Team researcher Katherine Chou in a blog post.
“Advanced machine learning can discover patterns in de-identified medical records to predict what is likely to happen next, and thus, anticipate the needs of the patients before they arise,” she added.
Google Brain is especially interested in putting machine learning to work predicting and preventing healthcare-associated infections, medication errors and hospital readmissions.” (J)

“On Thursday, the (Facebook) New York-based health unit hosted an invitation-only breakfast for pharmaceutical marketers to learn about targeting users for their clinical trials.
CNBC viewed a copy of the invitation, which asked participants to attend a presentation on the company’s “new clinical trials strategy.”
Facebook is already widely used by clinical trial recruiters. The sector is a massive revenue opportunity for the company. Research firm eMarketer estimates that pharma and health-care marketers will spend $3.1 billion on digital advertising by 2020, up from $1.9 billion last year.
According to a person who attended Thursday’s event, Facebook detailed how drug marketers can and can’t target users. The source requested anonymity because Facebook did not make the details public.
Facebook’s health team explained that users can’t be targeted based on health conditions like insomnia. This is not limited to clinical trials.
Marketers can target people by demographics and their expressed interests, or likes. Millions of health groups have organically popped up on Facebook for people with a variety of health conditions, though marketers can’t use that data in their outreach.” (K)

“One of IBM’s tentpole program within health care is the Watson for Oncology application developed in partnership with New York’s Memorial Sloan Kettering Cancer Center (MSK).
Some MSK oncologists have a highly specific expertise in certain cancers. By training Watson to think like they do, that knowledge expands from one specialist to any doctor who is querying Watson. That means that a patient can get the same top-tier care as if they traveled directly to the center’s offices in Manhattan. IBM’s Watson provides the framework to learn, connect, and store the data, while MSK is imparting its knowledge to train the computer.
The app, which can be run on an iPad or other tablet, is able to pack in all the expertise of MSK oncologists into one place so that any doctor anywhere is able to provide elite cancer care. This is significant for patients who live in areas without world-class medical services, like lower-income countries or rural America.” (L)

Artificial intelligence already found several areas in healthcare to revolutionize starting from the design of treatment plans through the assistance in repetitive jobs to medication management or drug creation. And it is only the beginning.
Mining medical records: The most obvious application of artificial intelligence in healthcare is data management….
Designing treatment plans: Watson for Oncology has an advanced ability to analyze the meaning and context of structured and unstructured data in clinical notes and reports that may be critical to selecting a treatment pathway. ..
Precision medicine: …Deep Genomics aims at identifying patterns in huge data sets of genetic information and medical records, looking for mutations and linkages to disease.
Drug creation:…Atomwise uses supercomputers that root out therapies from a database of molecular structures. “ (M)

Just six months after El Camino Hospital in Silicon Valley implemented artificial intelligence technology, the rate at which patients suffered dangerous falls dropped 39 percent. The key, alongside additional fall prevention strategies, was a software program that predicts which individuals are most likely to fall by combing over electronic health records for risk factors and merging the data discovered there with real-time tracking of patients.
“Every time a patient pushes a call light or hits a bathroom or bed alarm, it’s recorded,” says Cheryl Reinking, chief nursing officer at El Camino. The software takes that information and compares the rate at which a patient is requesting assistance to data such as what surgeries he’s had or which medications have been prescribed.
These data are all processed through “machine learning” – a form of artificial intelligence whereby computers take in new information and perform tasks based on it without being reprogrammed to do so. In this case, the program “learns” if a person may be more likely to fall based on his behavior and treatments. “Then it pushes an alert to the nurse saying ‘your patient in room 2308 is at risk right now for falling,'” Reinking says, after which that individual might be moved closer to the nursing station or monitored via video.” (N)

President Trump, “Nobody knew that health care could be so complicated.”

(A) The Upside of Being Ruled by the Five Tech Giants, by Farhad Manjoo, https://www.nytimes.com/2017/11/01/technology/five-tech-giants-upside.html?_r=0
(B) A digital revolution in health care is speeding up, https://www.economist.com/news/business/21717990-telemedicine-predictive-diagnostics-wearable-sensors-and-host-new-apps-will-transform-how
(C) Why Tech Giants Like Google and Apple Are Moving into the Healthcare Space, http://ventureclash.com/2016/06/29/why-tech-giants-like-google-and-apple-are-moving-into-the-healthcare-space/
(D) Prepare for the Digital Health Revolution, by Sy Mukherjee, http://fortune.com/2017/04/20/digital-health-revolution/
(E) Amazon Threat Causes Shakeout in the Health-Care Industry, by Robert Langreth , Jared S Hopkins , and Spencer Soper, https://www.bloomberg.com/news/articles/2017-10-26/drug-wholesalers-slump-after-amazon-com-obtains-state-licenses
(F) CVS Health’s surprising deal for Aetna? It’s all about Amazon, by Evelyn Cheng and Thomas Franck, https://www.cnbc.com/2017/10/26/cvs-deal-for-aetna-would-be-biggest-in-history-of-health-insurance.html
(G) Rumors, expectations surround Apple expansion into health care, by DARIUS TAHIR, https://www.politico.com/story/2016/10/apple-expansion-health-care-229111
(H) Microsoft’s new healthcare initiative, and the challenges of bridging tech and health, by CLARE MCGRANE, https://www.geekwire.com/2017/microsofts-new-healthcare-initiative-challenges-bridging-tech-health/
(I) Quest Diagnostics, Walmart partner to offer lab testing services in stores, by Alex Kacik, http://www.modernhealthcare.com/article/20170626/news/170629919
(J) Google strikes several hospital partnerships for machine learning research. Stanford Medicine, UC San Francisco and University of Chicago Medicine to help Google Brain fine-tune predictive analytics to spot patterns in EHRs, by Mike Miliard, http://www.healthcareitnews.com/news/google-strikes-several-hospital-partnerships-machine-learning-research
(K) Facebook brought drug marketers together to educate them on targeting consumers, by Christina Farr, https://www.cnbc.com/2017/09/07/facebook-held-a-breakfast-to-promote-clinical-trials-strategy.html
(L) MING THE HEALTH CARE INDUSTRY, by Laura Lorenzetti, http://fortune.com/ibm-watson-health-business-strategy/
(M) Artificial Intelligence Will Redesign Healthcare, by Arlene Weintraub, https://www.usnews.com/news/healthcare-of-tomorrow/articles/2017-10-31/hospitals-utilize-artificial-intelligence-to-treat-patients
(N) Hospitals Utilize Artificial Intelligence to Treat Patients, by Arlene Weintraub, https://www.usnews.com/news/healthcare-of-tomorrow/articles/2017-10-31/hospitals-utilize-artificial-intelligence-to-treat-patients

The Obama-era health care law actually has two major subsidies that benefit consumers with low-to-moderate incomes. The subsidy Trump targeted reimburses insurers for reducing copays and deductibles, and is under a legal cloud. The other subsidy is a tax credit that reduces the premiums people pay, and it is not in jeopardy.
If the subsidy for copays and deductibles gets erased, insurers would raise premiums to recoup the money, since by law they have to keep offering reduced copays and deductibles to consumers with modest incomes.
The subsidy for premiums is designed to increase with the rising price of insurance. So government spending to subsidize premiums would jump.
“This is where the counting gets sort of weird,” said Matthew Buettgens, a senior research analyst with the Urban Institute.
The nonpartisan policy research group has estimated that richer premium subsidies could entice up to 600,000 more people to sign up for health law coverage, depending on how insurers and state regulators adjust.
The group also found that the federal government would end up spending more overall on health insurance through higher premium subsidies.” (A)

“A bipartisan deal to shore up ObamaCare’s insurance markets would reduce the deficit by nearly $4 billion by 2027, according to a score released Wednesday by Congress’s nonpartisan scorekeeper.
The bill, sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would fund key ObamaCare insurer subsidies and give states more flexibility to change their ObamaCare programs.
The Congressional Budget Office (CBO) said in its report Wednesday that the bill would not substantially impact the number of people with health insurance.
On the flip side, a CBO report released in August concluded that not funding the insurer payments, called cost-sharing reductions, would increase the federal deficit by $194 billion through 2026.” (B)

Congressional Budget Office Cost Estimate of Bipartisan Health Care Stabilization Act of 2017
co-sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.)

Click to access bipartisanhealthcarestabilizationactof2017_0.pdf

“Utah Republican Sen. Orrin G. Hatch has dealt an emerging bipartisan health care bill a body blow…
“I can’t co-sponsor it because I don’t agree with it,” the Utah Republican said. “I think he’s trying to do a good thing, but it’s only temporary.”…
It would be very difficult for legislation related to overhauling the health insurance system to move through the Senate, let alone reach the president’s desk, without the support of the Finance panel chairman, given its broad jurisdiction over health care.
Republicans and Democrats alike think Trump could be convinced to support the bipartisan health care bill. But GOP members previously said opposition from either Hatch or Alexander would prevent any proposal related to the insurance markets from advancing…
“Some are working on an approach that amounts to little more than a congressional bailout of Obamacare, including pumping tens of billions of dollars into the already failing system in the form of cost-sharing reduction payments,” Hatch wrote in The Washington Post last month, referencing the HELP committee effort.” (C)

“Many Republicans, particularly the more conservative ones, are having a hard time reconciling themselves to passing a bill that props up the marketplaces which they spent most of the year trying to erase in several ACA repeal bills. Their lack of agreement became even more pronounced yesterday, as the Republican chairmen of two key House and Senate committees introduced an alternative to the Alexander-Murray bill that Democrats immediately panned.
The competing plan, from House Ways and Means Chairman Kevin Brady (R-Tex.) and Senate Finance Chairman Orrin Hatch (R-Utah) would fund the cost-sharing reduction payments, known as CSRs, just like Alexander-Murray. But it would go further by delaying the ACA’s individual and employer mandates and giving states even more leeway in opting out of insurer regulations.” (D)

“Senate Majority Leader Mitch McConnell (R-Ky.) said on Sunday he would be willing to bring a health-care bill to the Senate floor if he had confidence President Trump would sign it into law…
“What I’m waiting for is to hear from President Trump what kind of health-care bill he might sign. If there’s a need for some kind of interim step here to stabilize the market, we need a bill the president will actually sign,” he continued…
Trump slammed the bipartisan deal on Wednesday, saying on Twitter that he could not support “bailing out” insurance companies, which he accused of making huge profits from ObamaCare.
However, the president appeared to backtrack on Thursday, saying he could be open to a bipartisan short-term ObamaCare stabilization deal in the upper chamber. “We will probably like a very short-term solution until we hit the block grants,” Trump said. “If they can do something like that, I’m open to it.” (E)

“.. White House aide Marc Short insisted that Trump would consider the Alexander-Murray compromise only if the Democrats also agreed to repeal Obamacare’s individual mandate, which requires all Americans to get health-care coverage. The mandate is essential to Obamacare markets, ensuring that enough healthy people join the insurance pool to offset the costs of the sick. Cost-sharing reduction payments, on the other hand, would help calm markets if restored, but state insurance regulators have found reasonable ways of cushioning the shock insurance-buyers would face without them. So Trump essentially asked Democrats to blow up Obamacare in return for payments that might help it a bit. If Senate Minority Leader Charles E. Schumer (D-N.Y.) did not rule this out immediately, a five-minute call with practically any independent health-care expert would have revealed this proposal for what it is: an insult.” (F)

“Senate Minority Leader Chuck Schumer said Sunday that the Alexander-Murray bipartisan health care bill has support from a majority of senators, and he urged Senate Majority Leader Mitch McConnell to bring it to the floor “immediately.”
“This is a good compromise. It took months to work out. It has a majority. It has 60 senators supporting it. We have all 48 Democrats, 12 Republicans,” Schumer (D-N.Y.) said on “Meet the Press” on NBC. “I would urge Senator McConnell to put it on the floor immediately, this week. It will pass and it will pass by a large number of votes.”…
Schumer said President Donald Trump originally urged lawmakers to come up with a bipartisan health care fix, but he added that the president’s reluctance to support the bipartisan bill comes after the “right wing” attacked it.” (G)

A federal judge sided with the Trump administration on Wednesday in a ruling against 18 states that sought to compel the federal government to pay subsidies to health insurance companies for the benefit of millions of low-income people.
“It appears initially that the Trump administration has the stronger legal argument,” Judge Vince Chhabria of Federal District Court in San Francisco wrote in the ruling.
He refused to issue a preliminary injunction requested by the states, leaving the dispute to be resolved in a trial in his courtroom over the next few months.
The states, led by the attorney general of California, Xavier Becerra, contend that the payments are needed to prevent chaos and confusion in insurance markets during the annual open enrollment period, which starts on Nov. 1.
But Judge Chhabria said at a hearing on Monday that California and other states had found “a very clever way” to protect their residents against immediate harm from termination of the subsidies by President Trump. As a result, he said in his Wednesday ruling, many low-income people will be “better off or unharmed.’’
During Monday’s hearing, state officials told Judge Chhabria that cutting off the subsidy payments would cause immediate and irreparable harm to states and to consumers, increasing the likelihood that insurers would pull out of the marketplace…
But Judge Chhabria said California and most of the other state plaintiffs “saw the writing on the wall a long time ago — that the administration was going to terminate these payments to insurance companies to subsidize co-payments and deductibles.”
“California is doing a really good job of responding to the termination of these payments in a way that is not only avoiding harm for people, but actually benefiting people,” the judge added.
In his Wednesday ruling, Judge Chhabria wrote that low-income people who now have silver plans in some cases may be able to find gold plans with lower premiums and lower deductibles for 2018.
To offset the expected loss of cost-sharing subsidies, California added a surcharge to the price of midlevel silver plans sold on its Affordable Care Act marketplace. When premiums go up, consumers receive more financial assistance to help with premium costs, so in many cases they will be no worse off….
Many other states have taken similar steps to minimize harm to consumers, the judge said. He was appointed in 2014 by President Barack Obama.” (H)

“Republican lawmakers will not take up a bipartisan plan to stabilize Obamacare insurance markets or try again to repeal and replace the law this year, House of Representatives Speaker Paul Ryan said on Wednesday, signaling his party was shelving the matter until the 2018 U.S. congressional election year.” (I)

“The CMS proposed a rule late Friday aimed at giving states more flexibility in stabilizing the Affordable Care Act exchanges and in interpreting the law’s essential health benefits as a way to lower the cost of individual and small group health plans….
The CMS said the rule would give states greater flexibility in defining the ACA’s minimum essential benefits to increase affordability of coverage. States would play a larger role in the certification of qualified health plans offered on the federal insurance exchange. And they would have more leeway in setting medical loss ratios for individual-market plans.
“Consumers who have specific health needs may be impacted by the proposed policy,” the agency said. “In the individual and small group markets, depending on the selection made by the state in which the consumer lives, consumers with less comprehensive plans may no longer have coverage for certain services. In other states, again depending on state choices, consumers may gain coverage for some services.” “ (J)

“Josh Kushner and Jared Kushner both have backgrounds in investment, but that might be where the brothers’ similarities end…..Josh, meanwhile, embarked on a sort of post-election apology tour to investment partners, denying any Trump administration connections, and was photographed taking in the Women’s March on Washington. Even the brothers’ business interests are in opposition: Jared is a crucial part of the Trump administration team seeking to repeal Obamacare—whose exchanges underpin Josh’s health-insurance company, Oscar—by any means necessary….
But on Friday, he and his Oscar co-founder, C.E.O. Mario Schlosser, published a clear, if characteristically equivocal, rebuke of Trump’s A.C.A. repeal push, in an op-ed for Axios. “The administration’s cuts to outreach and sporadic lip service to repealing the ACA do nothing to stanch growing confusion among shoppers,” Kushner and Schlosser complain, carefully, about the potential for Trump’s health-care plans to upend their business. On the plus side, “Plans will be more affordable for millions of Americans due to the seesaw impact of cuts to cost-sharing reduction subsidies, which will actually increase subsidies for many low-income consumers,” they write. “And for the first time, the I.R.S. will be aggressively enforcing the individual mandate.”” (K)

(A) Trump’s plan to end health care subsidy could yield unintended consequence, by Ricardo Alonso-Zaldivar, https://www.csmonitor.com/USA/2017/1019/Trump-s-plan-to-end-health-care-subsidy-could-yield-unintended-consequence
(B) CBO: Bipartisan health-care bill would reduce deficit by $4B over 10 years, by JESSIE HELLMANN, http://thehill.com/policy/healthcare/357091-cbo-bipartisan-deal-would-reduce-deficit-by-4-billion
(C) Hatch Deals Blow to Bipartisan Health Care Bill, by Joe Williams, https://www.rollcall.com/news/politics/hatch-deals-devastating-blow-bipartisan-health-bill
(D) The Health 202: Trump is now the one holding up a health-care bill, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/10/25/the-health-202-trump-is-now-the-one-holding-up-a-health-care-bill/59ef549630fb045cba000a01/?utm_term=.067a1f1a14c4
(E) McConnell: I’d be happy to bring a health-care bill to the floor if I know Trump will sign it, by JULIA MANCHESTER, http://thehill.com/homenews/sunday-talk-shows/356593-mcconnell-id-be-happy-to-bring-a-health-care-bill-to-the-floor-if
(F) The latest terrible GOP plan to ruin Obamacare, by Stephen Stromberg, https://www.washingtonpost.com/blogs/post-partisan/wp/2017/10/24/the-latest-terrible-gop-plan-to-ruin-obamacare/?utm_term=.1f1eb70ba1c0
(G) Schumer: Bipartisan health care bill ‘has a majority’, by REBECCA MORIN, http://www.politico.com/story/2017/10/22/schumer-bipartisan-health-care-bill-has-a-majority-244040
(H) Siding With Trump, Judge Clears Way for Trial Over Health Subsidies, by ROBERT PEAR, https://www.nytimes.com/2017/10/25/us/politics/alexander-murray-congressional-budget-office-deficit-savings.html
(I) U.S. lawmakers will not tackle healthcare this year, Ryan says: Reuters interview, by Richard Cowan, Doina Chiacu, https://www.reuters.com/article/us-usa-healthcare-ryan/u-s-lawmakers-will-not-tackle-healthcare-this-year-ryan-says-reuters-interview-idUSKBN1CU1XW
(J) CMS to allow states to define essential health benefits, by Harris Meyer , Shelby Livingston and Virgil Dickson, http://www.modernhealthcare.com/article/20171027/NEWS/171029872?utm_source=modernhealthcare&utm_medium=email&utm_content=20171027-NEWS-171029872&utm_campaign=am
(K) JOSH KUSHNER POLITELY REBUKES HIS BROTHER’S BOSS FOR NUKING HIS BUSINESS, by MAYA KOSOFF, https://www.vanityfair.com/news/2017/10/josh-kushner-oscar-obamacare-op-ed

“The current opioid epidemic is the deadliest drug crisis in American history. Overdoses, fueled by opioids, are the leading cause of death for Americans under 50 years old — killing roughly 64,000 people last year, more than guns or car accidents, and doing so at a pace faster than the H.I.V. epidemic did at its peak.
President Trump declared the opioid crisis a “public health emergency” on Thursday, though he did not release additional funding to address it. Had he declared it a “national emergency,” as he promised to do in August, it would have led to the quick allocation of federal funds.” (A)

“Trump pledged throughout his 2016 campaign to make the opioid crisis a priority as president, and established a commission in June to address the problem, which Trump said killed 64,000 Americans last year alone. Just since he first suggested that he would declare a national emergency to attack the crisis on Aug. 10, some 10,700 Americans have died from overdoses, according to the commission’s estimates.
Instead, Trump’s presidency has brought an aggressive push for new healthcare legislation that guts funding to Medicaid, the primary source of coverage for mental health and substance use disorders. That prompted Republican senators from hard-hit states to propose separate funding of $45 billion to absorb the blow, a figure receiving pushback from some within the administration.
The declaration alone provides no additional money to combat the problem but allows existing grants to be redirected to better deal with the crisis. (B)

“In July, the White House opioid commission recommended that the president “make an emergency declaration” in order to “force Congress to focus on funding,” as the commission put it in their report. Trump announced shortly after that he would be making the move. But while Congressional Republicans, along with some law enforcement and physicians’ groups, have praised Trump’s directive on Thursday, others have said it falls short of the drastic effort required to combat the opioid crisis.
Trump did not, for instance, designate the epidemic as a national emergency, which is different than a public health emergency and would have released funds from the Federal Emergency Management Agency. Instead, the declaration frees up money from a public health emergency fund—which is currently worth only $57,000, according to Lev Facher of STAT. Experts have estimated that it will take billions of dollars to effectively address the opioid epidemic.” (C)

“Three months after calling for a national emergency declaration from President Donald Trump to deal with a surge in opioid overdoses, Gov. Chris Christie told Fox News on Friday that such a move was never his preference.
“That wasn’t the one I would have embraced the most,” said Christie, appearing on “Fox and Friends.”
In July, Christie’s opioid commission issued its interim report, informing the president that “the first and most urgent recommendation of this Commission is direct and completely within your control: Declare a national emergency under either the Public Health Service Act or the Stafford Act.”
Such a national emergency declaration under the Stafford Act would have given the federal government immediate access to billions of dollars in emergency relief funds to expand opioid treatment….
The president isn’t devoting any new funding to the fight against an opioid crisis. So what does his declaration do?
On Friday, Christie insisted the president had acted in accordance with his wishes.
“I would have gone for either one, either what he did yesterday, or the Stafford Act,” the governor told Fox News….
“Congress appropriates the money,” said the governor. “The president’s now said, he wants the money, and he wants it to be aggressive.”
The president has not made a specific request for funding from Congress.” (D)

“Here 7 takeaways that show what the declaration really means:
1. Trump didn’t declare a ‘national emergency,’ and that’s significant
2. So what does declaring a ‘public health emergency’ do?
3. Some drug treatment providers are ‘bitterly disappointed,’ others ‘hopeful.’
4. The feds are going to sue some drug companies
5. He’s cutting some red-tape to increase treatment availability
6. He wants to educate doctors and young people to ‘just say no’
7. He’s waiting on Christie’s final report to do more (E)

“The trips to resorts in the sun traps of Florida, Arizona and California were a great chance for medics to network, take a break from patients and learn about new treatments. There were even freebies – fishing hats, cuddly toys to take back for the kids, music CDs. And the visits were all expenses paid.
But such events laid the groundwork for a national crisis.
From 1996 to 2001, American drug giant Purdue Pharma held more than 40 national “pain management symposia” at picturesque locations, hosting thousands of American doctors, nurses and pharmacists.
The healthcare professionals had been specially invited, whisked to the conferences to be drilled on promotional material about the firm’s new star drug, OxyContin, and recruited as advocates, the US government later documented.
The pill comprises oxycodone, a semi-synthetic opioid loosely related to morphine and originally based on elements of the opium poppy. Such strong painkillers were traditionally used to ease cancer pain, but beginning in the mid-1990s, pills based on oxycodone and the similar compound hydrocodone began being branded and aggressively marketed for chronic pain instead – a nagging back injury from manual labor or a car accident, for example.” “(F)

“But while outrage ferments across the country, there’s one arena where a deafening silence remains: the nation’s largest wholesale drug distributors.
McKesson (MCK, -5.25%) , Cardinal Health (CAH, -3.43%) , and Amerisource Bergen (ABC, -4.17%) —collectively known as the “Big Three”—distribute a vast majority of the country’s prescription opioids. And the investigation found that they’ve spent millions of dollars on well-connected lobbyists and campaign contributions to get Congress to look the other way while they poured hundreds of millions of opioids into our communities, fueling the rampant epidemic of opioid addiction. They successfully stymied the Drug Enforcement Administration’s anti-diversion enforcement efforts and saddled the government’s ability to combat suspicious opioid orders.
Not only was this a deadly abuse of corporate power, it was duplicitous. After a decade of repeated enforcement actions by the DEA resulting in hundreds of millions of dollars in fines for failures to report suspicious orders of prescription opioids, the Big Three knew they needed to shift public perception. So the companies made public promises to strengthen their anti-diversion programs and compliance practices to avoid further scrutiny. However, behind the scenes, they continued to divert critical resources to circumvent the existing regulatory system.
Viewed in this light, the industry’s much-touted recruitment of former DEA employees appears more an exercise in gaming the system than developing best-in-class compliance practices.” (G)

“Democratic Sen. Joe Manchin of West Virginia slammed pharmaceutical companies on Thursday, arguing they should be held legally liable for their role in the ongoing opioid crisis.
“This is a business plan. They are liable,” Manchin told CNN’s Jake Tapper on “The Lead” when asked if he believes the pharmaceutical industry needs to be found legally liable in some cases for the prevalence of opioids in the United States.” (H)

“Here are five things the Trump administration could do today to ease America’s opioid crisis:
Equip all police officers in the US with naloxone
Expand medication-assisted treatment (MAT)
Mandate fresh training on opioids for doctors and dentists
Allow Medicaid to be used for in-patient addiction treatment facilities
Stop health insurers discriminating against addicts (I)

“Food and Drug Administration Commissioner Dr. Scott Gottlieb says the practice of over-prescribing opioids has helped drive opioid abuse. The Centers for Disease Control and Prevention reports that 33,000 people died from opioid overdoses in 2015 and more than 2 million people are addicted to the drugs.
The CDC found that most people who abuse narcotics got their first pills as legitimate prescriptions. Studies have shown the use of opioids during and after surgery as well as to treat injuries and chronic pain have skyrocketed in recent years, and addiction, overdoses and other abuse have tracked right along.
“It’s like cooking. You give a little of this, a little of that, and it’s better.”
“We need to take a little bit of ownership with this whole opioid epidemic and say, ‘what can we do?’” said Dr. Charles Hannon of the orthopedic surgery department at Rush who helped design a new approach to using fewer opioids among knee and hip replacement patients.
“Maybe it is something we can take on to play our own role in curbing this epidemic.”
Starting this past spring, the team tried a controversial approach, dialing back the amount of opioids used during surgery, and limiting what patients were given afterwards. Instead, they are sent home with Tylenol, the anti-inflammatory arthritis drug celecoxib, and an epilepsy drug called gabapentin that can also help manage pain….
Non-steroidal anti-inflammatory drugs (NSAIDs) such as celecoxib or ibuprofen not only help pain, but reduce inflammation.
“You take the Tylenol round the clock. You take the NSAID round the clock. You take gabapentin round the clock. Then if you have pain, then you take the opioid.” (J)

“There’s a quick and simple way President Trump could immediately help Americans addicted to opioids.
Here it is: allow Medicaid to start paying for treatment at large institutions for mental disease (known as IMDs). Under a current policy known as the “IMD exclusion,” people on Medicaid can’t get substance abuse treatment at facilities with more than 16 beds.
This policy shift isn’t explicitly part of the emergency declaration Trump issued yesterday at the White House, but the president did make a brief mention of it in his address.
“As part of this emergency response, we will announce a new policy to overcome a restrictive 1970s-era rule that prevents states from providing care at certain treatment facilities with more than 16 beds for those suffering from drug addiction,” Trump said…
Trump’s opioid commission, led by New Jersey Gov. Chris Christie (R), identified removing the IMD exclusion as the top way to make treatment available to patients immediately. “This is the single fastest way to increase treatment availability across the nation,” the report said.” (K)

“Yes, this is the most widespread and deadly drug crisis in the nation’s history. But there has been a long string of other such epidemics, each sharing chilling similarities with today’s unfolding tragedy.
There was an outbreak after the Civil War when soldiers and others became addicted to a new pharmaceutical called morphine, one of the first of many man-made opioids. There was another in the early 1900s after a different drug was developed to help “cure” morphine addiction. It was called heroin.
Cocaine was also developed by drugmakers and sold to help morphine addiction. It cleared nasal passages, too, and became the official remedy of the Hay Fever Association. In 1910, President William H. Taft told Congress that cocaine was the most serious drug problem the nation had ever faced.
Over the next century, abuse outbreaks of cocaine, heroin, and other drugs like methamphetamine, marketed as a diet drug, would emerge and then fall back….
Health officials are fighting the current epidemic on three fronts: Preventing overdose deaths, helping people recover from addiction, and preventing new addictions.
There appears to be some success on the first front. The number of new addictions may be receding…
The other two fronts — preventing deaths and treating addiction — are not so promising, despite more attention and money flowing to programs. Deaths are still rising, and University of Pittsburgh researchers estimate as many as 300,000 will die from overdoses over the next five years.” (L)

“Hear the rattle in the holler — that ain’t no snake,” crooned Marcus Oglesby, making a sound with his mouth like a shaken bottle of pills.
The song, performed by Oglesby’s Appalachian blues band Creek Don’t Rise, silenced the bar. It told the Barboursville, West Virginia patrons a story they already knew, about how opioids had unraveled families and leveled communities in West Virginia and across the nation.
The title of the song “White Coat Man” is a reference to the doctors who prescribed and the pharmacists who sold opioid pills in the state. The Charleston Gazette reported that during a six-year-period, pharmaceutical companies flooded 780 million opioid pills into West Virginia, where some 2 million people live.
“Things in the holler, they ain’t the same,
People in the holler can’t stand the pain.
Used to owe it to the company store,
Now the white coat man’s gonna own your soul.”
The song is infused with blues and country and paints a bleak picture. A hungry baby cries after a mother spends grocery money on pills. A miner is injured on the job, and “there came the pills.” A woman blames the doctor for her struggle with addiction after she was prescribed painkillers.” (M)

(A) The Opioid Epidemic: A Crisis Years in the Making, by Maya Salam, https://www.nytimes.com/2017/10/26/us/opioid-crisis-public-health-emergency.html
(B) Trump’s Emergency Declaration on Opioid Crisis Will Require Further Funding, by VIVIAN SALAMA, https://www.nbcnews.com/storyline/americas-heroin-epidemic/trump-s-emergency-declaration-opioid-crisis-will-require-further-funding-n814416
(C) Trump Declares the Opioid Crisis a Public Health Emergency. What Does That Mean?, by Brigit Katz, https://www.smithsonianmag.com/smart-news/trump-declares-opioid-crisis-public-health-emergency-180966998/
(D) Trump Declares Opioid Crisis a ‘Health Emergency’ but Requests No Funds, by JULIE HIRSCHFELD DAVIS, https://www.nytimes.com/2017/10/26/us/politics/trump-opioid-crisis.html
(E) 7 takeways from Trump’s opioids public health emergency: What it really means, by Claude Brodesser-Akner, http://www.nj.com/politics/index.ssf/2017/10/5_takeaways_from_trumps_public_health_emergency_de.html#incart_river_index
(F) America’s opioid crisis: how prescription drugs sparked a national trauma, by Joanna Walters, https://www.theguardian.com/us-news/2017/oct/25/americas-opioid-crisis-how-prescription-drugs-sparked-a-national-trauma
(G) The Big 3 Are Fueling the Opioid Epidemic. Now They Need a Watchdog, by Ken Hall, http://fortune.com/2017/10/20/60-minutes-opioid-crisis-big-three/
(H) Manchin: Pharmaceutical companies are liable for opioid crisis, by Amanda Golden, http://www.cnn.com/2017/10/26/politics/opioid-crisis-companies-liable-joe-manchin-the-lead/index.html
(I) Five things Trump could do right now to ease the opioid crisis, by Joanna Walters, https://www.theguardian.com/us-news/2017/oct/23/five-things-trump-help-ease-opioid-crisis
(J) To Fight the Opioid Crisis, These Doctors Cut Back on Opioids, by MAGGIE FOX, https://www.nbcnews.com/storyline/americas-heroin-epidemic/fight-opioid-crisis-these-doctors-cut-back-opioids-n814636
(K) The Health 202: There’s a no-brainer way to solve the opioid crisis, by Paige Winfield Cunningham, October 27 https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/10/27/the-health-202-there-s-a-no-brainer-way-to-solve-the-opioid-crisis/59f2058830fb0468e7653dc0/?utm_term=.b46a49804013
(L) Today’s opioid crisis shares chilling similarities with past drug epidemics, by Mike Stobbe, http://www.chicagotribune.com/news/nationworld/ct-drug-epidemics-history-20171028-story.html
(M) LISTEN: This blues song tells the story of the opioid crisis — and the ‘white coat men’ who started it, https://www.pbs.org/newshour/arts/listen-this-blues-song-tells-the-story-of-the-opioid-crisis-and-the-white-coat-men-who-started-it

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.

(A) http://well.blogs.nytimes.com/2016/05/03/medical-errors-may-cause-over-250000-deaths-a-year/?_r=0
(B) https://www.washingtonpost.com/national/health-science/exclusive-patient-safety-issues-prompt-leadership-shake-up-at-nih-hospital/2016/05/10/ad1f71f6-0ffb-11e6-8967-7ac733c56f12_story.html?wpmm=1&wpisrc=nl_evening
(C) http://www.jeromegroopman.com/how-doctors-think.html