Our Fractured Healthcare System: How One Patient Died Just Outside the ER

I read an article over winter break about a young woman’s death from an asthma attack. But the tragedy is that she died just a few feet away from the emergency room. Her name was Laura Levis, and she was 34.

A little after 4 a.m., Laura went to Somerville Hospital, a short walk from her apartment, because she felt an asthma attack coming on. She chose to walk the 375 feet to the hospital because her attacks came on gradually, and so she figured that she had enough time to get to the hospital, get treated, and go along her day. Normally, she would have gone to Mount Auburn Hospital with her husband to get treated for her attacks, but because of personal reasons she wen to CHA Somerville Hospital instead. Regardless, the change in hospital should not have played an impact.

Except that she didn’t make into the emergency room of CHA Somerville. She died a few feet away from the entrance.

What happened was that when Laura made it to CHA Somerville there was no bright “EMERGENCY” sign that we normally see at hospitals. It was darkness, and because Laura was unfamiliar with the hospital she chose to go to Entrance A because it was more lit. But when she arrived the doors were closed even though she saw a sign that said “EMERGENCY CHECK-IN” through the door. Panic set it, and for those with asthma, panic can worsen the attack.

While the hospital had a sign to direct patients to the actual emergency room, it’s unclear if Laura saw the sign. Surveillance video shows her walking in that direction, but she did not make it because when she was 29 feet away from the entrance she couldn’t walk anymore. The attack had become significantly worse that her only hope was to sit on the bench and call 911.

It gets worse. When Laura called 911 she was connected with a regional operator, and so Laura wasted no time explaining her dire situation. She explained that she was having an asthma attack, that she was outside the emergency room at Somerville Hospital, and that she felt that she was going to die. The operator connected with the local police, and so Laura had to explain the situation, again. But because Laura was in the middle of an asthma attack, she could hardly speak at the end of the call, so the regional operator jumped in the call.

“She’s outside of the Somerville Hospital,” said the regional operator, jumping in while still on the line. “She’s having an asthma attack. She can’t get into the hospital there.”

A satellite ping from Laura’s cellphone showed her location to be 68 Tower Street, but the police dispatchers needed a more precise location. They asked if she was at 230 Highland Avenue, the only address the dispatcher had for the emergency room because the hospital had not assigned its emergency room a specific address on Tower Street. But Highland Avenue is on the other side of the hospital, nowhere near Laura’s location. Had the regional operator stayed on the line with the police, then she could have told them that she was outside the emergency room.

Laura’s location is indicated by the red block. The ping off her cellphone is at location #1. But the dispatcher sent the ambulance to location #2. (Source: The Boston Globe)

At 4:25 am and 36 seconds, Laura uttered her last words.

I’m outside.”

At approximately 4:39 am, Laura was brought in the emergency room. About 13 minutes had passed without oxygen to her brain. Her chance of survival was slim to none.


SO WHAT HAPPENED?

When the police responders realized that Laura could no longer speak, they called Cataldo Ambulance to get to her location, which was still inaccurate and unclear at this time. The police then called the Somerville Fire Department and gave them a vague address saying that she was “probably on the Tower side”, neglecting to mention a very important piece of information that her cellphone pinged at 68 Tower Street, at the top of the hill. Because the information the Fire Department dispatcher received was vague, he had to rely on personal experience and went to the bottom of the hill. Again, more time wasted. The less likely that Laura was going to survive.

What is even more incredulous is that there is not direct line to the Somerville emergency room. So the police dispatcher had to call the night receptionist, who directed them to charge nurse. This whole process took 30 seconds. A nurse picked up the phone and went to go look for Laura. This nurse was sitting in Entrance A, the place Laura had first stopped at but found that its doors closed. According to the surveillance videos, the nurse takes one step out from the emergency doors and looks but doesn’t find Laura. The nurse would go back inside a mere 12 seconds later.

Laura’s location is the red block with the #3. The nurse is at Entrance A, 70 feet away from her. Entrance B is the emergency room Laura was trying to reach. It was only 30 feet away. (Source: The Boston Globe)

The nurse should not have even been the one to look for Laura. There was a security guard desk in Entrance A, but that desk was empty because the guards were on “patient watch”. Yet, one of the patrol officers overhead the nurse say something about the police and someone being locked out. The officer never asked the nurse for more info, and the nurse did not tell him anything.

Once she was done searching, the nurse told the dispatcher that she would call Laura’s cell phone. Except the nurse called from inside the emergency room, and so if she had called Laura’s phone number while standing outside she could have heard it ring or seen it light up. Laura was only 70 feet away from the nurse.

During an investigation, the nurse told the investigators that she could not see anything because it was “pitch black”, but the nurse never conveyed that information back to the police dispatcher. But if it was “pitch black”, then how was a surveillance camera able to clearly record Laura on the bench, 70 feet away from the nurse? There was enough light, and hospital officials would later agree.


IT GETS WORSE.

While Laura’s husband was by her bedside in the ICU, no one said a word to him that Laura was locked outside that door the night of her death. Hospital staff told him Laura had collapsed outside of the hospital and was unable to give the first responders an exact location, and he certainly didn’t think that any of them would lie to him. That she was less than 30 feet away from the entrance of the emergency room. She was that close to getting the care she needed.

After Laura’s death, her husband published a beautiful tribute and even thanked the doctors, nurses, respiratory therapists, and other staff members for their help. But for Somerville Detective Michael Laura’s death stuck by him. And so, Perrone conducted a full investigation into her death that he uncovered details that were not known by Laura’s family.

Once Laura’s husband read the police report, he went straight to Lubin & Meyer, one of the largest medical malpractice firms in Boston. Laura’s husband wanted to sue Cambridge Health Alliance, the organization that ran the Sommerville Hospital, a public entity. But because of a law enacted in the 1970s, it protects public hospitals from being sued for more than $100,000 and indemnified their employees.

Because malpractice firms operate off contingency fees, Lubin & Meyer would only receive, at maximum, $40,000 of the $100,000 verdict. $40,000 would certainly not be enough to bring her case to court.

Four weeks after Laura’s death, the Public Safety Officers held a meeting half of the emergency department’s staff to discuss “expectations of staff and public safety partners and providing a safe environment for both the staff and patients” according to a report by the Department of Public Health (DPH). Guess who has NOT at the meeting? The charge nurse who looked for Laura the night of her death.

The DPH’s report also found numerous patient-safety violations at Somerville and that the circumstances surrounding Laura’s death were not reported to DPH.


So Let’s talk.

If you are reading this and not morally outraged, then you and I need to sit down and discuss this story. Otherwise, I hope you are upset like me.

Let’s start at the beginning.

Laura was an active, energetic 34-year-old. You know what’s good for people with asthma? Being active, and Laura was certainly active. Yes, she was prone to attacks, but she had a routine that she established with her husband. She knew her attacks came on gradually, and so she knew she had time to walk to the Somerville emergency room. Yes, Laura most likely should have called her husband or her family, but that is not important. Yes, if Laura had a nebulizer treatment at home then perhaps she would have been able to treat her attacks herself. But keep in mind, the cost of these nebulizers varies, and we have no idea if Laura had the monetary means to get one at home. Or perhaps she simply felt more comfortable having her attacks treated in the emergency room.

Everything went wrong as soon as she was unable to get through the doors in Entrance A. There should have been a bright light indicating where the emergency room is at Somerville Hospital. Why was there no light? Why is our nation’s 911 infrastructure not equipped to work with our wireless world? Why was there so much communication breakdown among different providers and responders that Laura had to repeat her story multiple times? Why was information omitted among dispatchers and the nurse?

Why did the hospital not say anything to Laura’s husband and family? How will we protect individuals when they are hurt by public hospitals? Why is it that malpractice law firms fail as advocates for our patients?

Under the Emergency Medical Treatment and Labor Act (EMTALA), Somerville Hospital should have searched for Laura within 250 yards of the hospital, this includes sidewalks, parking lots, driveways, and other buildings. Laura was 70 feet away from the nurse and 30 feet away from the emergency room entrance. The 100 feet between Entrance A and Entrance B should have been searched because 100 feet is approximately 33 yards.

Leaving off with some good news.

Despite all the pain and frustration that Laura’s husband and family endured in the aftermath of her death, Laura’s husband received a phone call from the U.S. Department of Health and Human Services (HHS), Office of Inspector General. Somerville Hospital had been accused of violating federal law by denying Laura access to emergency care. The hospital had to cough up $90,000 to the government.

Our fragmented healthcare system has hurt so many people, and will continue to hurt more people if we don’t try to fix it anytime soon. We need to have robust communication systems where dispatchers can talk to each other and pass along information so that the patient need not to repeat the same lines over again. We need to strengthen our 911 infrastructure so that GPS coordinates are accurate. We need make sure the hospitals’ surrounding environments are lit up and helpful to patients. We need to encourage our physicians, staff members, and nurses to keep looking if they can’t find it. We need a less fragmented system.

Let’s empower patients and put them back in the center of care. Let’s minimize risk and maximize benefit. Let’s be innovative.

Let’s be better America.

Article link for more in-depth reading

Future of Healthcare

If there is anything that people should pay attention to before midterm elections, it’s healthcare. Politics aside, we are seeing major disruption beginning to happen. Amazon/Berkshire Hathaway/JP Morgan are coming up with a plan to provide easier access to their employees; Google is starting to get its footing in healthcare, Apple is doing the same, Uber/Lyft are trying to make it easier for their customers to get to the doctor. You also have Oscar Health, which is trying to disrupt the health insurance market, which needs to be improved soon. While I don’t know if these disruptions will be successful, I see a clear trend. Big companies are taking it into their hands to change healthcare because they are getting impatient with the government and its politics (also because healthcare is a $3 trillion business). When people rely on hospitals, insurers, and pharmaceuticals to change healthcare they are not going to see much change because these stakeholders don’t want to do anything that will hurt their income.

               I’m going to focus on each “sector” of healthcare and delve deep into what the problems these sectors are facing, and who can help. This is all tentative but based off of research.

Hospitals

  • One big problem that we are facing is the closure of hospitals in rural areas. The wage index is lower for these hospitals, and so it’s becoming harder to keep these hospitals open and serve people.

    • What happens is that the Medicare wage index reimburses hospitals based on market conditions, such as the local cost of living and hospital wage rates. Hospitals in rural areas tend to receive lower wages than those in urban and city-like neighborhoods. The fairness of this wage index has already lead to 82 closures of rural hospitals, although this statistic was taken back in January of this past year.

  • Billing is another huge problem facing hospitals. Hospitals are billing, billing, and billing patient’s outrageous amounts of money.

    • Kaiser Health News did an article a couple of months ago about a hospital asking patients to pay back their costs by signing a loan with a bank. Usually, what these patients pay with insurance is less than what the hospital is asking them to pay with the loan because the insurers are usually able to negotiate a lower price with hospitals. In this case, hospitals can have the power and charge patients the full price.

  • Lastly, the government is cutting Medicare payments to hospitals. 1.6 Billion Dollars to be exact.

    • Hospitals are the largest employers in the U.S. so cutting payments means less money for hospitals, so we are going to see hospitals kick patients to the curb sooner or start firing physicians in areas that are deemed “not profitable” (i.e., urology).

  • With all of the vertical mergers that are happening in healthcare, large hospital chains are beginning to swallow up smaller hospitals or other healthcare service centers (i.e., radiology centers).

    • What happens is that these chains have more power in these areas and can force the hospitals and centers that it swallows to charge its prices, which are often higher. Those places that are not swallowed by the chain often have a hard time staying afloat. Hospital consolidation has been happening since 2009, but the public has recently started to protest against this.

The Future of Hospitals

  • The American Hospital Association (AHA) has such a huge presence on The Hill that it will be very hard to pass a bill that prevents hospitals from overbilling.

  • However, CMS recently release its rural health strategy. It tries to increase access to telehealth and reduce regulatory burden but does not address the unequal wage index. I would not be surprised if we see more rural health closures à greater health disparities.

  • Speaking of telehealth, expect it to be a big part of healthcare in the next couple of years. Google and Apple are leaping into the healthcare market, and with their technology expertise, I wouldn’t be surprised to see them as leaders of telehealth. However, interoperability and security of telehealth will be two issues they need to tackle before we see telehealth take off.

  • Expect more consolidations. As long as mergers are happening, expect consolidations to grow and that hospitals will begin to cut off some departments.

  • If Dems take back Congress, then maybe we would see a slight reduction in the Medicare payment cuts. It’s hard to predict politics because you never know if/when something will change.

Physicians

  • Physicians are getting a lot of heat right now. Patients are getting overcharged on so many items, that some even go into near bankruptcy after a major health scare.

  • Tech companies are experimenting with AI, but Google says that AI won’t replace with your doctor.

  • But you might not have a primary care physician in the future since primary care physicians are on the decline. Multiple factors play into this, such as income decline, the changing physician-patient relationship, and a decrease in graduates applying to primary care programs.

  • Be on the lookout for a decrease of physicians accepting Medicaid because the reimbursements are close to nothing. Even with Medicaid expansion, physicians aren’t obligated to accept those with Medicaid.

The Future of Physicians

  • Most likely will see a decrease in primary care physicians.

  • Keep an eye out on Google and Apple to see what they can do with AI.

  • Telehealth will be huge for physicians, especially for communities in rural areas. But don’t expect an immediate impact.

  • Physicians themselves are often clueless about the real costs of their examinations, but sometimes they do know.

  • What medical schools should focus on is educating physicians to be advocates for their patients. Patients and physicians can work together in the future to decrease costs

  • Expect the physician-patient relationship to change.

  • Telehealth will influence it as well, and patients will become more empowered with the use of the Internet (i.e., googling their symptoms). Patients will also expect more out of their doctors, and educated patients may also question their doctors’ choices

Insurers

  • Because the individual mandate was repealed, we are going to see ACA premiums increase.

    • CBO predicts that premiums will increase by about 10 percent in 2019.

  • Protection for pre-existing conditions is not a partisan issue, and it is the number one aspect of the ACA that Congress still wants to keep.

  • Unless you live in Minnesota, Alaska, or Oregon, expect your health insurance premiums/deductibles to grow because these three states have federally approved reinsurance programs.

    • These programs protect insurers by offsetting the high costs of some individuals.

  • Association health care plans are also a go. That means that small businesses can get together and enroll in a plan together, with the hope of lower costs.

    • However, the concern is that these plans did happen before and there were massive fraud and regulatory issues. Additionally, healthy young people are most likely to enroll in these plans, so that means the sicker and older are going to stay in the ACA marketplace a higher costs for these folks because they are going to cost more.

  • Insurers are the middlemen, and many stakeholders dislike middlemen these days. There’s a lack of choice and high cost when it comes to insurance.

  • There have been some huge vertical mergers happening. CVS-Humana, CVS Health-Aetna, and Cigna-Express Scripts. All are trying to make healthcare easier to navigate and decrease costs.

    • When these mergers are approved, then the smaller insurance companies are going to have a hard time negotiating costs since these mergers will have a huge influence.

The Future of Insurers

  • Keep an eye out for Oscar Health. It’s disrupting the health insurance company by utilizing technology and transparency to get customers.

  • Oscar is expanding to Florida, Michigan, and Arizona in addition to the six other states it currently is in. It’s received mixed reviews, but it’s a step in the right direction for health insurance companies.

  • Lowe’s, Boeing, and Walmart are directly negotiating prices with hospitals for care for their employees.

    • They are skipping the middlemen, which are insurance companies in this case, and going straight to the source. I wouldn’t be surprised if more companies follow them.

  • Follow the mergers!! I think they should all be approved since they are vertical mergers, but it’ll be interesting to see how they affect the industry. Will they work, or won’t they? Only time will tell.

  • Atul Gawande, the newly-appointed CEO of the Amazon/JP Morgan/Berkshire Hathaway merger, says that he wants to get rid of the middlemen. If this merger works and they do end up sharing their knowledge, then insurance companies are going to be in big trouble because they thrive off of no knowledge.

  • Keep an eye to see whether insurers will continue to stay in the ACA exchange. I’m not sure how many more parts of the ACA are going to be repealed, but I’m sure that insurance companies are keeping a close eye on the exchanges and how participating in them will affect their prices.

Pharmaceuticals

  • If there is one item that everybody can agree on it is that people want transparency from the pharmaceutical sector.

    • They want to know how much profit these companies are pocketing while charging extremely high prices and jacking up old ones (i.e., the whole EpiPen fiasco).

  • Secretary Azar just recently released a plan to revamp Medicare Part B drugs that the pharma industry hates because now we will only be paying 126 percent of what countries are pay for drugs as compared to 180 percent.

  • Drug reimportation is getting traction again. High drug costs mean that people are often turning to Canada and Europe to get their drugs at a lower price.

    • Politics says that this legislation will not get passed anytime soon.

  • Pharmacy benefit managers (PBM) are getting a lot of heat these days. They are the middlemen between insurers and pharmaceutical companies.

    • People don't like them because they believe that they raise the price so that they can keep the profits. There’s also been a lack of transparency with these group of individuals.

  • The 340B Program has been quite controversial this past year with no sight of a resolution.

    • The 340B Program was supposed to help rural, small hospitals get drugs at a lower cost but because of its loose restrictions, its become a profit-making machine. Hospitals can purchase these drugs at a low cost and then make patients pay high costs for them.

The Future of Pharmaceuticals

  • Expect there to be more noise about the high costs of pharmaceutical drugs.

  • It’ll be hard to pass any legislation that will demand transparency from pharma companies because of the heavy influence of PhRMA on the Hill.

  • The Right to Try legislation is the beginning of an era where patients are getting more power in their care.

  • This changes the patient-physician relationship dramatically but also undermines the importance and authority of the FDA.

  • The 340B Program will continue to be a battle between hospitals and pharma companies. Whether hearings will help alleviate this tension will be unknow, but for now, both sides refuse to accept fault.

  • With the CVS-Aetna merger, retail clinics will become the next big thing when it comes to buying drugs and accessing care.

  • The Cigna-Express Scripts merger hopefully will hopefully try to remedy the problem about pharmacy benefit mergers, but only time with tell.

Patients

  • It may not seem like it, but patients can have the biggest impact on healthcare.

    • Patients are becoming more knowledgeable and active in healthcare, especially since it is one of the focus issues for the upcoming midterm election.

  • Patients recognize that the system is rigged against them, and so they’re changing their relationships with their physicians and trying to have the best care possible at the lowest cost.

  • All of the mergers are focused on helping patients, so it will be interesting to see if these mergers end up making the system be for the patients and whether patients are receptive to this.

  • For those who have iPhones, patients are now able to see their health records if they go to certain hospitals. MedStar and Johns Hopkins are two hospital systems that allow their patients to access their records on their iPhones.

  • We’re beginning to see a transition into chronic diseases, where patients are more likely to live longer but with a disease or two.

    • Diabetes, arthritis, asthma, and heart disease are just a couple of the most common diseases.

  • The 65+ population is going to increase dramatically over the next 15 to 20 years, which means more people are going to be enrolled in Medicare.

    • Whether Medicare can handle this drastic increase is another debate, but the demographics of our population is changing.

    • This new 65+ population will want care that is patient-centered and does not want unnecessary testing.

    • Companies and stakeholders in healthcare need to be ready for this transition and start preparing for this aging population.

The Future of Patients

  • Patients will continue to empower themselves when it comes to getting their healthcare.

  • They will want more choices but at a lesser cost.

  • Patients will want things to be mobile and make it easier for them to find in-network physicians and care.

  • The 65+ population will have a huge impact on healthcare, so the delivery of healthcare and the affordability of healthcare will be hot topics.

  • Technology will be of a great aide for patients, but not all patients will benefit from these technology advances.

    • An example is the Fit Bit. Yes, it’s helpful for those who are trying to lose weight or are fitness professionals, but for those who are healthy and exercise it may not be of use to them.

  • With new technologies that help patients monitor their lifestyles, we will start seeing patients pay more attention to their wellness and lifestyle.

  • The hope is that patients will realize that they don’t need medication, but rather a change in lifestyle may be all they need.

    • However, social determinants of health can affect whether a patient can change his/her lifestyle. Your living community and finances can influence your ability to lead a healthy lifestyle.

  • Clover Health is a new tech startup that is focused on providing care to seniors in the Medicare Advantage PPO program. In other words, it’s a company that provides care for seniors who have an additional insurance plan to Medicare.

Simply put, the future of healthcare can go in any direction. There are so many tech startups that are entering in healthcare, and they have the potential to disrupt the industry. However, when you are competing against companies that have been in the industry for a long time, you will inevitably start with some losses. Both Oscar Health and Clover Health put up losses before making some progress.

But the bright side is that companies realize that the current system is not working. Insurance companies are merging with pharmacies to create a smoother process for patients, while Amazon is aiming to overhaul the entire system. Google and Apple are continuing to apply for patents to use their technology to make it easier for people to live their lives. Ultimately, all of the healthcare reform is centered on increasing access and decreasing cost.

Nationalized Healthcare -- What is it? And can we have it?

A good friend of mine is finishing up his study abroad in Japan. He, like many students who live in an unfamiliar environment for a long time, became sick. Because Japan has a national healthcare system, he was automatically enrolled when he started studying there this past spring. And so, he went to the on-campus clinic, filled out the forms, and got some prescriptions. The whole visit lasted only an hour. The total cost for this visit: $15!!! For comparisons, I usually have to pay a co-pay of $20 just for my annual check-up. He then went to the pharmacy and picked up three different types of medicine. The total cost for these medicines: $5!!!!!! Yeah, sure Tylenol and Motrin might cost me $5 if I go to Target, but that is the price of one prescription. 

Nationalized healthcare is just another term for universal healthcare.

In Japan, that means that everybody has access to healthcare and the system is also "free." By free, I mean that it is a public system, and the patients only have to pay a small fee. In this case, my friend only had to pay $20 for his visit and three medicines. The whole process also just took up about one hour of his time.

Here's the important thing about nationalized healthcare. It does not imply that everybody gets everything for free. The government decides what is covered, who is included, and how much is covered. It's as close to a public option that you can get. There are different ways to fund a nationalized healthcare system. Japan uses a social health insurance system that combines public and private providers. You get your insurance through yourself if you are self-employed or through your job or government entity, whichever one that you work for. Insurance ends up paying around 70% of the costs, and the patients are usually responsible for the rest. Again, it is often a nominal amount. Also, those with preexisting conditions can get insurance with no problem. 

Sounds great right? Low cost, high-quality healthcare? Who doesn't want that? Well, be careful. Every great healthcare system has its cons. According to the Washing Post, because it is so easy to see a doctor in Japan, the government has been having a hard time preventing people from overusing or abusing the system. Another essential feature of Japan's system is that it does not pay doctors very highly. And so, doctors are faced with long hours and low pay and high stress. This is especially relevant for doctors working in public hospitals. 

So can the U.S. have a nationalized healthcare system or something like it?

It's complicated. We have two options on the left. One is Medicare for All, and the other is the less liberal public option. 

Bernie Sanders has been a champion of Medicare for All for a very long time now. Under this plan, the U.S. would have a universal healthcare system. It would be a federally administered single-payer health system. Sound familiar? Bernie wants his policy to cover any service with little cost to patients. Bernie's plan also wants to integrate our healthcare system so that we have one big public health insurance system that ensures that patients get the same quality of care. More and more Democrats are supporting Medicare for All, but not all Democrats want to embrace it. 

The public option (there really should be a name for it) is a milder version of Medicare for All but still aims to increase the government's involvement in healthcare. It was once deemed as too liberal to be included in the ACA, but now moderate Democrats are embracing it. There have been some variations of it. Democrat Cindy Axne defines public option as allowing Americans to choose between Medicare and Medicaid. Democrat Tom Malinowski supports creating a universal health coverage that people can buy into. For some, the public option is seen as a path to get to the end goal, Medicare for All, but for others, the public option is the end goal itself. However, the underlying common denominator is that these Democrats want to use the government's bargaining power to control healthcare costs. However, when we put pressure on prices, the question becomes how will this affect quality? 

Like all policy solutions, we have to deal with the dreaded politics.

Politics in healthcare is complicated and annoying. According to the New York Times, the pharmaceutical industry spends $204 million on lobbying, and the insurance industry only spent $157 million. As of right now, the American Medical Association (the lobbying organization for health professionals) has doled out $6 million in lobbying. We have a system here in the U.S. so entrenched in politics that if we try to do something to increase transparency or decrease costs that we will almost always see these stakeholders fighting back. 

When we talk about implementing a public insurance system and getting rid of the private insurance system, we are talking about eradicating some huge companies. Aetna, UnitedHealthcare, and Anthem are some of the most significant health insurance companies. These players have been in the system for a very long time, and so they will not go away willingly. 

If the U.S. were to follow Japan's path or something similar, then will our doctors accept a cut to their payments? They most definitely will not take it passively. Even now, physicians are very reluctant to accept Medicaid patients because the reimbursement rate is so low. Rather, if the government is going to decrease payments to physicians, then we need to figure out how much can we cut before we sacrifice quality and hurt patients? 

I'm not saying that we can never have a nationalized healthcare system, but when we talk about this, we need to consider the politics. We need to think about how will the stakeholders react? Is it feasible to get to the end goal all at once or do we need to take baby steps? Rebuilding a healthcare system will take years and even longer see benefits come from it. Changing the U.S.' system to a nationalized system will mean that we will be putting patients first. It says that we want to decrease costs but not sacrifice quality. But of course, each system will have its cons. But for now, the question becomes how do we work with the different stakeholders if we want to push for a nationalized healthcare system? How do we make sure that the politics stream allows for the policy solution to pass? If we can answer that question, then maybe we can be on the path to universal healthcare. 

 

 

Career Advice With CEO Jeff Galvin of American Gene Technologies

On campus, one of the clubs I am involved in is AcademyHealth, which is healthcare networking club to provide students majoring in healthcare management and policy or those interested in healthcare with opportunities to learn and connect with healthcare professionals. Our first event this semester was a Q&A session with CEO Jeff Galvin of American Gene Technologies. AGT is currently working on a medicine to cure HIV/AIDS and eventually cancer and other health diseases. They do this by working on cutting out the bad genes and inserting good genes. Their solutions are highly creative, so I would suggest keeping up with them if you are interested in biotechnology.

Anyways, onto the career advice. Mr. Galvin had some great pieces of wisdom, and I thought that I would share them with everybody since we are all in the process of looking for internships/jobs.

1. Focus on Developing Your Brain

If you focus on learning and growing your mind, then you can set your sights on anything. These days, if you are into consulting or investment banking (two very popular careers on Georgetown's campus), then you need to be a creative problem-solver and an analytical thinker.

And so, learning new ideas that you have not been exposed to can help you grow your mind and grow as a person. The only security that we have is our brain.

How does growing our brain help us in our career? Because at Georgetown you have to take courses in theology, psychology, economics, politics, etc..., we are knowledgeable about different subjects and have trained our brains to be able to adapt to the different courses we are learning. In real life, you will be exposed to new ideas, new rules, and new perspectives and having a flexible mindset will allow you to succeed by adapting quickly and developing a skill set.

2. Be Passionate!!

You can have a 4.0 and top-notch extracurriculars, but if you are not passionate about the company's idea, then it will be tough for you to excel in your position. People who are passionate are always willing to learn and grow. You have to follow that core inside of you. 

So whatever opportunity you encounter to make sure you are passionate about it. As cliche as this sounds, if you love what you do, then you won't work for a single day!

3. Appreciate Those Hard A's

We've all had those classes. The ones we thought we were going to fail, and so we study and lock ourselves in the library. And then we take the final, and we see that we got an A?! It's those A's that take a lot more effort to achieve that matter more than the A's that we knew we were going to receive the minute we walked into class. 

It's those hard-fought A's that will cause us to challenge ourselves and grow and develop a new skill set. You learn a little something new everytime you get that hard-earned A. Maybe it was studying a different way or learning to ask for help. Whatever it is, just know that you have grown and developed. 

4. Happiness and Peace of Mind

If you're going to compete on one thing, compete for happiness and peace of mind. Well, at least for Mr. Galvin and me, that is our definition of success. Yes, money is nice and all, but if we focus on the materialistic aspects of our life, then wouldn't it be a kind of empty life? If we are all millionaires, then aren't we all just poor?

We should aim to achieve happiness and peace of mind instead. We should welcome everybody and be inclusive as a society. 

Because at the end of the day, if you are wealthy but lonely, are you successful? 

5. Don't Worry About Making the Right Choice - The Only Right Choice is Investing in Yourself

The world is always changing, and sometimes we all feel a little lost in it. I know that I sure do whenever I see my classmates posting about new internships or positions that they have received. It is so hard not to compare ourselves to others, but we should just focus on ourselves. 

But you have to do you. What do you want to spend the rest of your life doing? What are your values? If you figure out the answer, then follow that path that will lead you there. And of course, there are multiple paths but follow the one that you think best suits you. 

But also be aware of reality. Read the news every day so that you can see reality and plan ahead of the curve. Continue to develop yourself and grow your brain. Companies are continually reinventing themselves so that they seem fresh and brand-new. You should do the same for yourself. But don't accept everything because it makes you feel safe. Go against the norm. People might call you crazy, but that is because it is something different. 

So, focus on yourself and be aware of reality. Those who do that will continue to find success throughout their lives. 

6. Have a Plan A, Plan B, and Plan C

I usually have only a Plan A and Plan B, but after hearing Mr. Galvin talk about how he also has a Plan C, I might start having on too. 

Plan A is the aspiration. What is your end game? The answer to the classic "where do you see yourself in 20 years?" question. 

Plan B is realistic. Eliminating all the idealism that exists, what is that you think you can realistically achieve? You can get to Plan B anytime because it is realistic and not full of fairytales. 

Plan C is survival. Just an extra blanket of security. For those who are worriers, Plan C is the plan for you. In case everything falls apart if you have a Plan C, then you will be okay.

Ultimately, you want to stay above Plan C because then everything is open to you. You can get to Plan B anytime because it is realistic, and maybe Plan A but that involves a considerable amount of realism and recognizing all the forces at work that can potentially change your situation.  

I have to say that I learned quite a lot from CEO Jeff Galvin and felt quite inspired and uplifted after the networking session. Sometimes, all we need is a little bit of advice to reenergize us and convince us to keep chugging along. 

Gun Violence Research

When the Parkland shooting occurred, the media and news outlets began to report on the ban that prevented CDC from conducting gun violence research. To give some background, this ban came from Rep. Dickey (R-Ark.) who added this amendment in 1999 to the CDC appropriation bill. The amendment states that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” To clarify, the amendment prohibits the CDC from advocating any gun-control policy, only prevents the organization from using its funding to research gun violence. But we all know that with no money there is no research. This amendment has shown up every year, but the Obama administration reversed this, but the Trump Administration kept this amendment. However, the most recent funding bill reverses the Dickey amendment, but unless there is money added to the appropriations bill, then there is nothing anything different.

If you're wondering why gun violence is considered a public health issue, it is because of this.

According to the Gun Violence Archive,

In 2017, 61,331 incidents involving guns occurred. 15,549 of these incidents results in deaths.

In 2018, 12,838 incidents have occurred. 3,283 of these incidents have resulted in deaths.

When over 60,000 incidents involving guns occur every year, and 25% of those result in death, then it should be classified as a public health crisis. The CDC needs to study these trends because proper research informs good policy. And then there is the balance between the 2nd amendment and protecting people.

The Role of Mental Health

President Trump blamed the ease of access mentally ill people have to guns and the underfunding of mental institutions. Associating mentally ill people with any gun violence is a complicated issue.

Think of this as a Venn Diagram. One side is the people who are mentally ill. The other side is people who commit gun violence. In the middle is the small intersection of people who are mentally ill and commit gun violence. However, not all gun violence perpetrators are mentally ill, and not all mentally ill people commit murders and shootings. Take gang violence for example. These shooters are mentally competent, but we do not often hear about these shootings because the media and news outlets don't cover it. And so, the shootings we often hear about are the ones committed by mentally ill people

It is essential to not stereotype all mentally ill people as people who will go on and be violent and hurt people because it will further stigmatize mentally ill people, making it possibly harder to help this community.

Reform vs. Politics

39 days after the Parkland tragedy, Gov. Rick Scott of Florida adopted into law the state's first gun control legislation. This law tightens gun control, allows some teachers to be alarmed, covers the role of mental health, and increases the minimum age requirement to purchase a gun from 18 to 21.

Guess who subsequently filed a federal lawsuit after this law was signed? The NRA! The organization alleged that raising the minimum age requirement impinges on people's 2nd and 14th amendment rights and that current law already prohibits those under 21 to not be able to purchase certain types of guns. In case you're wondering how powerful the NRA is, just know that it spent over 50 million dollars in the last election. Most of the money was directed to target ads against Democrats instead of supporting Republicans. 50 MILLION.

People often ask why our government does not enact gun control reform after each tragedy because it seems like every other country has learned to pass reform after there a mass shooting, most noticeably Australia. However, these countries do not have an organization that is nowhere as powerful as the NRA and as involved in elections as the NRA is.

Politicians are continually thinking about reelection and to win they need their donors to be on board. These high-profile donors often have stipulations that politicians need to serve otherwise they won't get the money. So the question becomes are politicians serving their donors or their constituents? One last bit on the NRA, there is an influential NRA lobbyist in Florida who kills any gun control law that comes up.

Here's an interesting New Yorker article on her: https://www.newyorker.com/magazine/2018/03/05/the-nra-lobbyist-behind-floridas-pro-gun-policies

As for why Gov. Scott, who is a Republican, enacted a gun-control reform. It can mostly be traced to the fact that he is running for Senate. Passing a gun-control overhaul and showing your constituents that you care about them and their safety will help the Governor win some votes. For Gov. Scott, the politics stream was aligned for him to adopt this legislation. For the other shootings that have happened before the Parkland one, the politics stream may not have been aligned for politicians to want to pass gun reform. But because it was politically advantageous for Gov. Scott, he wanted to pass reform even though it most likely alienated his base.

So where does this leave us? Well, issues have become so politically polarized that we forget about the constituents and the people who are suffering. Politicians become so entangled in the blame game and defending themselves that no reform often happens. But at the end of the day, how would you feel if you saw on the news that a shooting occurred at the school your siblings go to? Or a shooting happened at a movie theater where your parents are? Or what if it was you who was trapped in a shooting?

Gun violence is a systematic issue. You have powerful lobbyists and an organization with deep pockets and influence. But you also have young activists who have survived mass shootings and refuse to let their voices be unheard. But you also have a government that currently does not seem to be supportive of gun control. I don't see a solution anytime soon, given how political gun control is, but there has been progress, and we may need to be patient, but we can NOT give up.

So keep on making your voices heard. Don't give up. And don't forget the tragedies that have happened.

 

 

Amazon + Berkshire Hathaway + JP Morgan = Total Disruption?!

The title may be slightly exaggerated, but in case you didn’t hear, Amazon, Berkshire Hathaway, and JPMorgan are going to create a healthcare company!!! There had been whispers that Amazon was thinking about entering the pharma business, which would no doubt cause panic among pharma companies. The recent mergers among pharma companies and hospital systems show that everybody was bracing for Amazon’s entrance into the pharma business. But I guarantee you that nobody saw this mega merger coming.

Berkshire Hathaway is the third largest public company in the world. Oh, and Warren Buffett is the CEO of the company, so NBD. JPMorgan is the largest bank in the United States. Amazon is Amazon. For the rest of the article, I’ll be referring to these three companies as “the big three.”

There haven’t been any detailed specifics about the merger, but one of the main reasons why the big three merger is happening is because of the high costs of healthcare. I suspect that the federal government’s recent inability to pass any significant healthcare reform to address these costs is another reason. The big three hope that this merger will help their employees find healthcare.

I italicize employees because this merger is specifically for the people who work for these three companies. That’s why I don’t think that this merger will majorly disrupt the healthcare industry, but if this merger is successful, then I think many of the healthcare companies will have something to worry about.

What I expect the big three to do is to self-insure, which means that they’re going to take on all of the risks. They will most likely allocate a specific number of funds just for healthcare usage for their employees. That means that they will have to be pretty accurate when it comes to predicting the healthcare usage of their employees. Insurance companies won’t like this because, by self-insuring, the big three will be effectively cutting out these insurance companies because they used to be the middleman.

I wouldn’t be surprised if the big three introduced A.I. for their employees. Inefficiency has long haunted the healthcare industry, and if technology can eliminate these inefficiencies, then I wouldn’t be surprised if they introduced digital health. Especially with Apple moving into the EMR business, I don’t think that Amazon, Berkshire Hathaway, and JPMorgan will want to be left behind. You can read about my opinions on using data in healthcare down below in my post about data ethics.

I hope that the big three will focus on empowering primary care doctors, as the healthcare industry doesn’t give them much power, which is part of the reason there are such high costs in healthcare because we focus on medicating instead of treating the underlying cause.  

It’ll be interesting to see how the big three merger turns out and whether it is successful. Whether it succeeds or not, I think we can expect to see a new movement of businesses taking the healthcare problem into their own hands because they are frustrated with the government’s inability to pass any healthcare reform. I mean states are beginning to create safe injection sites, especially those suffering from the opioid crisis because they are tired of waiting for the federal government to give them money for the crisis. We discussed this in my Politics of Healthcare class today, and the problem when you have the free market start to create their own healthcare companies you will see someone people get left out and those are typically the low-income people. When the government provides healthcare, it does its best to include those low-income people, and so we have to keep in mind the social justice impact when we have these type of mergers. 

Another important note to mention is that on the day of the announcement, shares of big healthcare companies plummeted. If the stocks of groups such as UnitedHealth Group and Anthem go down just by the announcement of the big three merger, then imagine the disruption the actual merger will have on the stock market.

I’m not sure when this big three company will emerge, but I’ll be blogging about it when it happens.

Also, let me know in the comments what you think about this big three merger!  

Data Ethics and Healthcare

This past Thursday I had the opportunity to attend a conversation about data ethics hosted by the Kennedy Institute of Ethics, which was very informative. Did you know that the reason women feel cold in rooms is that the room temperature was regulated by the average metabolic rate of MEN?! I didn’t know that either…crazy am I right. I felt that the conversation about data ethics was very much related to healthcare, especially with Apple going into the EMR (Electronic Medical Records) business, so I thought that I would write a bit about data ethics and healthcare.

Before I begin, I’d just like to clarify that EMRs are our medical records but in electronic form. The healthcare industry has mixed opinions about EMRs because they’re a bit annoying. A provider usually has to fill out all of the required information before they can close it, and so it makes their jobs a bit more tedious. Anyways, Apple going into the EMR business is huge because well it’s Apple and it’ll be interesting to see how they integrate their Health app into EMRs.

Okay, now onto the conversation about data ethics.

They had four panelists, Rick Smolan, Cathy O’Neil, Mayra Buvinic, and Chuck Todd. I’ll be writing in the order of the panelists and what their main points were and how it all relates to healthcare.

Rick Smolan

  • His main project concerning data ethics was creating a map that showed where prisoners were going after they were released from incarceration. It turns out these prisoners were going to the same block as before, and so the block was dubbed the million-dollar block because the government is spending millions of dollars moving these people back and from their block.

How Does This Relate to Healthcare?

  • Well if Rick used data to track people’s movements, then data in healthcare can do the same thing, and providers can use that data to see if their patient is getting enough exercise or moving enough in the day. However, the question is whether this is a breach of privacy? Data in healthcare can help providers and insurance companies tremendously, but we must be aware of using the data solely for health reasons and not for profiteering reasons.

Cathy O’Neil

  • Cathy was by far my favorite panelist and had so much to say about data ethics, but the biggest takeaway I took from her was that we are using algorithms to predict success. However, if let these algorithms to dictate our decisions then sometimes they may do more harm than good. Cathy also brought up the point that we might need to an algorithm regulator because we abuse the use of algorithms.

How Does This Relate to Healthcare?

  • Well, say we use algorithms to predict the quality of doctors. If they get a good quality score, then they can keep practicing, but if they get a bad quality score, then they have to go to training or are banned from practicing in that area. If the algorithm is essentially a random process with no mathematical or logical reasoning behind it, then it might tell us to fire the good doctors and keep the bad doctors. Algorithms are used to predict the future because we like to know about the future, but they can be dangerous if there is no basis behind these algorithms and if there’s no regulator behind them.

Mayra Buvinic

  • Mayra didn’t talk much during the conversation, but she had a very important statement about data. Data can lie, and when we believe these lies, then society is in big trouble. People often will manipulate data or not include parts of it so that the data can support their points. This is extremely dangerous because people follow the data, and they will believe it.

How Does This Relate to Healthcare?

  • In healthcare, we often use data to support the growth of ACOs or the expansion of Medicaid/Medicare. And guess who decides whether we expand Medicaid/Medicare? Elected officials. If we manipulate data to convince our elected officials not to expand these programs or decide to block grant them, then millions of people are in danger of losing their healthcare. Data should be used as a supplement, but it should not be abused to hurt others.

Chuck Todd

  • Chuck focused his points on political campaigns, and how they’re primarily run on data. If you’re a reliable Democrat/Republican, then you will most likely have your door knocked on when it campaigns season rolls around. However, if you often switch parties, then your door probably doesn’t get knocked on too much. Chuck believes that campaign practices like these will lead to successful campaigns because they are going after their reliable voters, but it can lead to bad governance because we neglect a huge part of the voters.

How Does This Relate to Healthcare?

  • Say we use data to determine whether we should build another physician facility in the neighborhood. The data they have contains the names of those who regularly go to the doctor. Well, that data might not include those who are uninsured and are afraid to go to the doctor because they don’t want to get turned away. These people might be the one’s who need to see a doctor, but because they don’t go to the doctor, then their names are included in the dataset. What might happen is that we deduce from this data survey that this neighborhood doesn’t need a new physician facility because it seems like everybody has access to doctors. However, we need to be aware of what the data leaves out and how that affects final policy decisions.

Overall, big data is a field that is emerging and can shine some new knowledge about everything. However, we must remember to use data to aid society and not to harm society. We must not take advantage of people and must not use the data to harm others.

What is the 340B Program??!!!

I've been seeing this program floating around in my healthcare subscriptions, and so I decided to do some digging because it's related to pharmaceuticals and pricing, which is a topic I enjoy reading and researching. 

If I were to state the program's purpose in a very simple sentence, I would say that the 340B program was established to provide outpatient drugs for hospitals located in low-income populations. 

  • The program recipients care called "covered entities" and includes six categories of hospitals:
    • Disproportionate share hospitals
    • Children’s hospitals and cancer hospitals exempt from the Medicare prospective payment system
    • Sole community hospitals,
    • Rural referral centers
    • Critical access hospitals
  • There are more details as to what qualifies a hospital as a "covered entity" but just know that these six categories are the most common recipients for this program.
  • There are also eleven categories of non-hospital covered entities that can be eligible for this program, but for this article we'll just focus on the hospitals. 

I'm going to briefly go over the process of how hospitals get these discounts and pass them onto patients, but the majority of this article is going to focus on why this program is being abused. It's quite unfortunate because it is a great program with a great purpose. 

The Process

  1. Entities that think that they qualify for the program can apply online in the first two weeks of any calendar quarter (between the 1st day and 15th day in each month). 
  2. Facilities that are approved will receive the discounts beginning the first day of the next calendar quarter after the calendar quarter in which the entity completed the registration.
    1. EX: Hospital A completed registration in January 14th and was approved. Hospital A can start receiving discounts on February 1st. 
  3. The discounts are not on every drug. They are only available for the eligible drugs. 
  4. Covered entities will then give these discounted drugs to eligible patients. 
    1. An eligible patient must have an est. relationship w/the entity and the entity must have a record of the patient's care
    2. An eligible patient must receive care from a professional employed with the entity.
    3. An eligible patient must receive health services that are consistent with the services for which grant funding has been provided to the entity
      1. In other words, a patient can NOT receive a discounted drug if their only care is getting the drug. There must be other care in the visit as well. 

So why is this program being abused? Well if you read the eligible patient section carefully, you would have noticed that the program did not specify if the patient had to be enrolled in a specific insurance program. That means that patients with private insurance or Medicare can receive these discounted drugs. While this program was meant to target the low-income patients and the uninsured, it seems that there are more people benefiting from the program than they intended to. 

The problem worsens because pharmaceutical companies are giving out discounts, which doesn't help them because they aren't making as much money off these drugs as they used to, and hospitals are able to purchase these drugs for less money while possibly getting reimbursed the same amount if they had purchased these drugs for the usual amount.

  • Let's take a lemonade stand. I will call my stand RST, and RST sells lemonade for $10. Now, the government has created the 340B program and now I have to discount my lemonade for my "covered entities" to the price of $5. Side note: in real life, the drugs are discounted between 25 to 50 percent. 
  • Now instead of making $10/cup of lemonade, I am only making $5/cup of lemonade. While, my "covered entities' are still getting the same benefit, a cup of lemonade, at half the price of what they used to pay.
  • Now, if I am a rational person, then it is logical for me to be upset with this program because I am making less money while my "covered recipients" are getting all the benefits. 

And thus, the 340B program has evolved in a revenue maker with hospitals abusing their power in this program. Pharmaceutical companies say that they will pull out of the program, which will leave many people in danger because they need these drugs to be healthy. Hospitals do not want it either because they need to help their patients, and let's be honest they most likely enjoy making that money. 

How Do We Reform 340B? 

I don't have a clear-cut answer for this, but I do believe that the program's policies should be revised. It has strayed too far away from its original intent to only help needy patients, and so its policies must reflect its true mission. Eligible patients must also be under Medicaid or have no insurance. When we let people with private insurance benefit from a program that is intended to only help the needy, we start to stray away from the original mission. 

However, at the end of the day, the healthcare industry is a business trying to make a profit. And so, it is understandable why hospitals do not want to reform the 340B program, but helping the needy and making a profit are two different things and can not be combined together. 

Share your thoughts down below about what you think of the 340B program? Whose at fault? Pharma? Hospitals? Both? 

For more information about the 340B program, check out this link that I used for this article: https://www.340bhealth.org/340b-resources/340b-program/overview/

 

 

Children’s Health Insurance Program (CHIP)

You’ve seen this word floating around social media and newspaper articles for some time now. I’m here to address what CHIP is and why you should care about it. 

What is CHIP?

HIP tands for Children’s Health Insurance Program. It’s a federally funded program that provides low-cost health coverage for children in families and pregnant mothers who earn too much to qualify for Medicaid but still find it hard to afford health insurance. This program benefits an estimated 9 million children and 375,000 pregnant mother. Eligibility varies from state to state, and CHIP is often closely tied with the states’ Medicaid programs. Benefits include, but are not limited to: routine check-ups, immunizations, doctor visits, prescriptions, dental/vision care, inpatient/outpatient hospital care, laboratory and x-ray services, and emergency services. Some states offer more benefits, so check with your state to see what benefits your state offers. Routine “well-child” visits and dental visits are free, but some states require a monthly premiums or copays at each visit. However, CHIP ensures that families won’t have to pay more than 5% of their family’s income on healthcare costs. 

Families/pregnant mothers can apply for CHIP at any time in the year. If they apply for Medicaid coverage, then they can find out if their children qualify for CHIP. 

CHIP is a popular act that receives bipartisan support from both political parties, which is a huge deal given that both sides don’t agree on much. 

The takeaway here is that CHIP is federally-funded (states fund a tiny bit as well) program that provides low-cost health coverage for children and pregnant mothers. It’s also in danger of disappearing. 

Why Should I Care About CHIP?

Before I dig in, I need to go back to 2009. When Obama signed the ACA in 2009, he also signed the Children’s Health Insurance Program Reauthorization Act (CHIPRA). This act authorized for the program to exist through 2019. Also, the act gave significant new funding to CHIP and gave incentives for covering children through Medicaid and CHIP. One of its goals was to help states identify, enroll, and retain health coverage for children. The Secretary of Health and Human Services (HHS) was tasked to identify ways to measure the quality of care that was provided through CHIP. It’s important to make sure that programs that provide low-cost care don’t provide low-quality care. 

Fast forward to September 30, 2017. Why is this date important? Well, on that day federal funding for CHIP EXPIRED. 

When states run out of funding, they can dip into their unused federal funds, but those funds will only last for so lon. In fact, some states have ran out of funding in December 2017, and most states will run out of funding by the summer. As a result, states will have to begin to unravel their programs, leaving millions without coverage. 

While the Senate Finance and House Energy and Commerce committees were discussing a bill that continued authorization of CHIP through 2022 and renew funding until 2020 where afterwards the funding levels will return back to pre-ACA levels. 

Hopefully, the lawmakers will renew funding for CHIP, as it is a great program and aids millions of people. But, the program itself should NOT be a bargaining tool for lawmakers because this program should have been refunded back in September. There will always be politics in healthcare, but politics should NOT prevent people from having healthcare. 

NPR article to check out with some good information about CHIP: https://www.npr.org/sections/health-shots/2017/10/03/555166767/lapse-in-federal-funding-imperils-children-s-health-coverage

 

Decoded: The Better Care Reconciliation Act - aka the Senate version of the American Healthcare Act

Ah, the bill is finally out! The title: The Better Care Reconciliation Act. GOP can't lose more than three senators if they want this bill to pass, and right now they have way more than three senators who are not so hot about this bill. To help you understand this new bill and how it is "different" from the House version, I took the liberty of reading all 142 pages of it and other sites to help me best convey this piece of information to you. 

As for the timeline, the CBO has taken the bill and will be grading it and presenting its review sometime next week. In addition, Senate Majority Leader Mitch McConnell may or may not be meeting with those Republicans who are iffy about the bill so that they can get it to pass. All of this is supposed to be done by the July 4th recess, which starts on July 3rd and lasts till July 7th. Yup, that gives the Senate a week to get everybody on board so that they can pass it. 

So off to decoding and understanding this bill we go. I went in order of the bill and highlighting the most important aspects of it. 

Sec. 102 - eligibility of tax credit

The ACA had given tax credits to those living below 400 percent of the federal poverty line. This bill lowers the percentage to only 350 percent of the federal poverty line. Side note: the federal poverty line is a contentious issue because people disagree what that amount should be. Living in New York vs. living in Missouri are two very different lifestyles. Anyways, that means fewer people would be helped to afford healthcare. 350 percent of the federal poverty line: $41,580 for individuals and $85,050 for a family of four. 

In addition, for people who are low income, the act expects them to kick in more into their insurance plans. So the act doesn't help low-income people as much as the ACA does. For example, according to the chart in the act, a 55-year-old woman who makes 275% of the federal poverty line would have to kick in 10.5% of her income into her health insurance. Under the ACA, the same woman would only have to kick in 8.21% in. 

Sec. 104 - the individual mandate

All you need to know about this section is that it is gone. Byeeee individual mandate. Republicans hated this and now they have crossed it from the list. That means that healthy people might not continue to have health insurance because they won't be penalized for it --> so sick people might be the only ones with insurance. This bill replaces the mandate with no alternative though. 

Sec. 106 - state stability and innovation program

This program was created to help those that were hurt by Obamacare. This section is divided into short-term assistance and long-term assistance. You don't need to know the specific amounts but just know that the government is giving money to the Center of Medicaid and Medicare Services (CMS) to help high-risk individuals afford premiums and other services. States will have to submit an application to the Administrator of the CMS to get money to help the people in their state. Eventually, the money given to this program decreases as the years pass on because it assumes that people are more well adjusted. 

Sec. 108 - 119 - repeal of taxes/limitations

Some noteworthy ones listed in that section: 

  1. Repeal of taxes on employee health insurance premiums and health plan benefit
  2. Repeal of taxes on over-the-counter medications and prescribed medications
  3. Repeal of taxes on health savings accounts
  4. Repeal of medical device excise tax
  5. Repeal of health insurance tax
  6. Repeal of tanning tax

Sec. 121 - increasing amount put into Health Savings Account (HSA)

People can now put more money into their HSA. How much? The amount increased to the amount of their deductible and out-of-pocket limitations. So a lot of money. People like it because that money they deposit is not subject to the federal income tax. 

Sec. 126/127/128 - Medicaid

Ah the section that everybody is wondering about.

 Right now the government pays 95 percent of all costs for those in Medicaid. This bill decreases the amount that the government would be paying. By 2023, it would only be responsible for 75 percent of the costs, which is essentially cutting the Medicaid expansion program. Not a very good deal for states because they are responsible for more costs, so some may decide to leave the program.

Section 127 and 128 cover the funding aspect of Medicaid. The program is moving towards a "per capita" system where the government decides how much to give to the state for each enrollee. The problem is that the lump sum that is given to state does not take into account rising healthcare costs. For example, in the year 2020, $20,000 may not cover the same amount of treatment as it did in the year 2018.

 Sec. 1903B - Medicaid flexibility program

The Medicaid flexibility program is a phrase to denote each state's flexibility to design their own healthcare programs to meet their needs.

The reason I put this section in this article is that under this section the program includes mental health and substance abuse coverage. I think that this is a great addition because we currently do not have much legislation going on that addresses mental health issues and/or substance abuse, especially with the ongoing heroin/opioid epidemic.

But if there is anything you should now is that this bill hurts lower-class and middle-class Americans. If you have been following this post, then you know that there are two major cuts. One is that the people eligible for tax credits to pay for the insurance have decreased dramatically. The second is the cutting of Medicaid expansion funding. Remember, Medicaid is to help individuals afford healthcare. But this bill does prevent insurance companies from charging a higher price for those with preexisting conditions. 

We'll see what the CBO comes out with next week after they do their estimating and math. 

And that is it. The big takeaway from the Better Care Reconciliation Act. I only highlighted the sections I thought were important but below I have linked the two resources I used to write this post. 

CNN: http://www.cnn.com/2017/06/22/politics/republican-health-care-bill-text/index.html

Vox: https://www.vox.com/policy-and-politics/2017/6/22/15846728/senate-plan-better-care-reconciliation-act