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Waiting on Mitch’s Healthcare Bill …

Today is the Mitch McConnell says the text of the Senate ACHA bill will be revealed. After the unveiling of the bill, we will have to wait until next week for a CBO score. The Senator’s goal is to have a bill through by the break for the Fourth of July holiday.

U.S. Senate Republicans plan to unveil the text of their draft healthcare bill on Thursday as senators struggle over issues such as the future of the Medicaid program for the poor and bringing down insurance costs.

Republicans in the chamber have been working for weeks behind closed doors on legislation aimed at repealing and replacing major portions of the Affordable Care Act, former Democratic President Barack Obama’s signature healthcare law, popularly known as Obamacare.

The effort has been plagued from the start by tensions between moderates and conservatives, which surfaced again on Tuesday. Democrats have also criticized the behind-the-scenes meetings, staging a protest on the Senate floor on Monday.

“Republicans are writing their healthcare bill under the cover of darkness because they are ashamed of it,” Senate Democratic leader Chuck Schumer charged.

Many Senators have expressed that they do not know what is in the bill. It is believed that a group of 13 Republican Senators has been working in secretive, closed-door sessions.

Here is what is known to be in the bill…

The bill is expected to repeal the biggest parts of the Affordable Care Act, including the individual mandate and the employer mandate. It is also expected to defund Planned Parenthood for one year by kicking the women’s health organization out of the Medicaid program. That provision could be dropped if Senate Majority Leader Mitch McConnell needs votes from key moderates who oppose it….

It would eliminate Obamacare’s subsidy program and replace it with a different structure to help low-income people afford insurance. But Republicans are still trying to craft an alternative that would prohibit coverage of abortion without violating the strict reconciliation rules enabling them to pass the bill without a Democratic filibuster….

The bill is also expected to dramatically reshape Medicaid. Instead of an open-ended entitlement, states would get a set amount of money per person. In a win for conservatives, the Senate is expected to cut the program as aggressively as the House did until 2025 or 2026 and then make payments that grow in line with inflation. States are expected to have significant new flexibility for how they run their Medicaid programs. Republicans are likely to include a carve-out for certain children with complex medical needs, according to several sources…

The bill is expected to repeal Obamacare’s taxes, but how soon that is done is fluid because it would likely depend on how much tax revenue is needed to cover other costs associated with the GOP plan….

Public approval for the House version is dropping, even with Republican voters. It is predicted that the Senate version will be equally unpopular…

And while 16 percent of Republican voters opposed the bill in late April, about 30 percent of such voters now say they are against the bill, the Morning Consult/Politico survey found…

Just 35 percent of all voters now approve of the House bill, down from 42 percent at the end of April, according to that poll.

Another survey, also released Wednesday, found that majorities of voters oppose all the key provisions found in the House bill — even in congressional districts that voted strongly for Republicans in recent elections.

 

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Opioid Deaths Skyrocketing …

Yesterday, the Washington Post report that opioid deaths in the U.S. have skyrocketed since 2005 according to a government report issued this month by the Healthcare Cost and Utilization Project.

The 2014 numbers, the latest available for every state and the District of Columbia, reflect a 64 percent increase for inpatient care and a 99 percent jump for emergency room treatment compared to figures from 2005. Their trajectory likely will keep climbing if the epidemic continues unabated.

The report, released by the Agency for Healthcare Research and Quality (AHRQ), puts Maryland at the very top of the national list for inpatient care. The state, already struggling with overdoses from heroin and prescription opioids, has seen the spread of the synthetic opioid fentanyl, which can be mixed with heroin or cocaine and is extraordinarily powerful. Gov. Larry Hogan (R) this year declared a state of emergency in response to the crisis.

The roots of the problem of opioid addiction are as old as history, but, the recent spike in opioid addiction and overdoses are attributed to two main factors, pain becoming a vital sign that a doctor looks at during an examination (remember the introduction of the smiley face posters for pain) and an extended release version of oxycodone released in 1996.

Fifteen years ago, a report by the Joint Commission on Accreditation of Healthcare Organizations, a nationally recognized medical society which accredits hospitals, stressed that pain was vastly undertreated in the United States. The report recommended that physicians routinely assess pain at every patient visit. It also suggested that opioids could be effectively and more broadly used without fear of addiction. This latter assumption was entirely mistaken, as we now understand. The report was part of a trend in medicine through the 1980s and 1990s toward treating pain more proactively.

The report was heavily publicized, and today it is widely acknowledged that it led to massive – and sometimes inappropriate – increases in the use of prescription opioid drugs to treat pain.

With more opioids being prescribed by well-meaning doctors, some were diverted from the legal supply chain – through theft from medicine cabinets or trade on the black market – to the street for illicit use. As more opioids leaked out, more people started to experiment with them for recreational purposes…

The second major factor was the introduction of an extended release formulation of the potent opioid oxycodone in the 1996. You may know this drug by its brand name, OxyContin. In fact, you might have been prescribed it after having surgery.

The drug was designed to provide 12-24 hours of pain relief, as opposed to just four hours or so for an immediate release formulation. It meant that patients in pain could just take one or two pills a day rather than having to remember to take an immediate release drug every four hours or so. This also meant that OxyContin tablets contained a large amount of oxycodone – far more than would be found in several individual immediate release tablets.

And within 48 hours of OxyContin’s release on the market, drug users realized that crushing the tablet could easily breach the extended-release formulation, making the pure drug available in large quantities, free from harmful additives such as acetaminophen, which most recreational and chronic abusers find irritating, particularly if they inject it intravenously. This made it an attractive option for those who wanted to snort or inject their drugs. Surprisingly, neither the manufacturer nor the Food and Drug Administration foresaw this possibility.

When one looks at the states that have the highest death rates for opioids, one can easily correlate this to the high number of prescriptions per 100 people. West Virginia,  Ohio, and Kentucky have a rate of 96 to 143 prescriptions written to people. New Hampshire has a rate 72 to 81 prescriptions per 100 people. These numbers just astonished me. But, the sources of people that abuse these drugs vary widely.

Most people who abuse prescription opioids get them for free from a friend or relative. However, those who are at highest risk of overdose (using prescription opioids nonmedically 200 or more days a year) get them in ways that are different from those who use them less frequently. These people get opioids using their own prescriptions (27 percent), from friends or relatives for free (26 percent), buying from friends or relatives (23 percent), or buying from a drug dealer (15 percent). Those at highest risk of overdose are about four times more likely than the average user to buy the drugs from a dealer or other stranger.

What will the Trump administration do about the opioid crisis? Well, not much that will be productive.

The White House is calling for a 95 percent funding cut for the Office of National Drug Control Policy, the agency leading the charge against the country’s opioid epidemic, according to sources knowledgeable about the White House’s draft budget for the coming fiscal year. ONDCP is responsible for coordinating drug prevention programs across federal agencies and was slated to fund President Donald Trump’s much-lauded opioid commission.

The budget would slash ONDCP’s $380 million budget to $24 million. It would eliminate the High Intensity Drug Trafficking Areas program, which coordinates local, state, and national efforts to reduce drug trafficking and has a $250 million annual budget. It would also cut the Drug-Free Communities Support Program, which funds community-based youth substance abuse prevention programs. The budget calls both programs “duplicative of other Federal programs.” The budget is a “passback” draft: it was cleared by the White House budget office last week, but will still need to be approved by Congress.

On the campaign trail, Trump promised to “spend the money” to address the opioid epidemic, but his proposed budgets and policies thus far would drastically cut federal funding to tackle the issue.

MAGA

 

 

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Why the US does not have universal health care, while many other countries do

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House Speaker Paul Ryan walking into the Capitol on May 4, when the House voted narrowly to accept a bill he shepherded to replace Obamacare.
Andrew Harnik/AP

Timothy Callaghan, Texas A&M University

The lead-up to the House passage of the American Health Care Act (AHCA) on May 4, which passed by a narrow majority after a failed first attempt, provided a glimpse into just how difficult it is to gain consensus on health care coverage. The Conversation

In the aftermath of the House vote, many people have asked: Why are politicians struggling to find consensus on the AHCA instead of pursuing universal coverage? After all, most advanced industrialized countries have universal health care.

As a health policy and politics scholar, I have some ideas. Research from political science and health services points to three explanations.

No. 1: American culture is unique

One key reason is the unique political culture in America. As a nation that began on the back of immigrants with an entrepreneurial spirit and without a feudal system to ingrain a rigid social structure, Americans are more likely to be individualistic.

In other words, Americans, and conservatives in particular, have a strong belief in classical liberalism and the idea that the government should play a limited role in society. Given that universal coverage inherently clashes with this belief in individualism and limited government, it is perhaps not surprising that it has never been enacted in America even as it has been enacted elsewhere.

Public opinion certainly supports this idea. Survey research conducted by the International Social Survey Program has found that a lower percentage of Americans believe health care for the sick is a government responsibility than individuals in other advanced countries like Canada, the U.K., Germany or Sweden.

No. 2: Interest groups don’t want it

Even as American political culture helps to explain the health care debate in America, culture is far from the only reason America lacks universal coverage. Another factor that has limited debate about national health insurance is the role of interest groups in influencing the political process. The legislative battle over the content of the ACA, for example, generated US$1.2 billion in lobbying in 2009 alone.

The insurance industry was a key player in this process, spending over $100 million to help shape the ACA and keep private insurers, as opposed to the government, as the key cog in American health care.

While recent reports suggest strong opposition from interest groups to the AHCA, it is worth noting that even when confronted with a bill that many organized interests view as bad policy, universal health care has not been brought up as an alternative.

No. 3: Entitlement programs are hard in general to enact

A third reason America lacks universal health coverage and that House Republicans struggled to pass their plan even in a very conservative House chamber is that America’s political institutions make it difficult for massive entitlement programs to be enacted. As policy experts have pointed out in studies of the U.S. health system, the country doesn’t “have a comprehensive national health insurance system because American political institutions are structurally biased against this kind of comprehensive reform.”

The political system is prone to inertia, and any attempt at comprehensive reform must pass through the obstacle course of congressional committees, budget estimates, conference committees, amendments and a potential veto while opponents of reform publicly bash the bill.

Bottom line: Universal coverage unlikely to happen

Ultimately, the United States remains one of the only advanced industrialized nations without a comprehensive national health insurance system and with little prospect for one developing under President Trump or even subsequent presidents because of the many ways America is exceptional.

Its culture is unusually individualistic, favoring personal over government responsibility; lobbyists are particularly active, spending billions to ensure that private insurers maintain their status in the health system; and our institutions are designed in a manner that limits major social policy changes from happening.

As long as the reasons above remain, there is little reason to expect universal coverage in America anytime soon.

Editor’s note: this is an updated version of an article that originally ran on October 25, 2016.

Timothy Callaghan, Assistant Professor, Texas A&M University Health Science Center, Texas A&M University

This article was originally published on The Conversation. Read the original article.

Your teeth are connected to your body

Which is something insurance companies are reluctant to acknowledge.

As the distance between rich and poor grows in the United States, few consequences are so overlooked as the humiliating divide in dental care. High-end cosmetic dentistry is soaring, and better-off Americans spend well over $1 billion each year just to make their teeth a few shades whiter.

Millions of others rely on charity clinics and hospital emergency rooms to treat painful and neglected teeth. Unable to afford expensive root canals and crowns, many simply have them pulled. Nearly 1 in 5 Americans older than 65 do not have a single real tooth left.

1 in 5

Americans older than 65 do not have a single real tooth left.

Over two days at the civic center, volunteer dentists would pull 795 teeth. A remarkable number of patients held steady jobs — a forklift operator, a librarian, a postal worker — but said they had no dental insurance and not enough cash to pay for a dentist.

Matello had both problems, adding to her frustration about being cut off from a world that many wealthier Americans take for granted.

“The country is way too divided between well-off people and people struggling for everything — even to see the dentist,” she said. “And the worst part is, I don’t see a bridge to cross over to be one of those rich people.”

The last person you’d expect to die in childbirth

NICU 1960

Many years ago, I used to be a childbirth educator, and apprenticed as a lay midwife. I attended a couple of dozen births, and delivered one all by myself.

After all these years, this story made me cry. Preeclampsia is not a bolt from the blue. We’ve known for the past century it’s related to inadequate blood volume and nutrition (back when I trained, the research of Dr. Tom Brewer in Chapel Hill showed it to be the result of calorie, salt, and protein deficiency). Some research indicates strenuous exercise as a factor.NICU 1960

And yet, doctors persist in saying it can’t be predicted. As soon as I read this woman’s symptoms, I knew right away what it was. Why didn’t her doctors?

ProPublica Share on Facebook Share on Twitter Comment Donate Bryan Anselm for ProPublica The Last Person You’d Expect to Die in Childbirth The U.S. has the worst rate of maternal deaths in the developed world, and 60 percent are preventable. The death of Lauren Bloomstein, a neonatal nurse, in the hospital where she worked illustrates a… Continue Reading →

Twitter after the vote

READ THIS THREAD:

Flashbacks

Charlie Pierce had his gall bladder out last week, and reading this made me start to relive my own experience:

From this standpoint, with my Mississippi plastics worker hanging out at the side of my bed, I watched the Republicans fall all over themselves trying to destroy the Affordable Care Act while pretending they weren’t doing that very thing. (An atypical presentation of a common condition.) For a good, long, healthy while, I was completely one of The American People, my privileged view of our democratic follies clouded for a moment by more than just the pharmaceuticals. I was looking through a haze of frustration and pain, and considerable anger, for me and for my phantom pal from the plastics plant. Human health is not a commodity, to be bargained and sold and traded as though it were any other consumer good.

I was lying in a hospital, doped to the gills, chatting in my mind with an imaginary fellow citizen, and I could figure that out. Why in bloody hell can’t they? They’re out to wreck the only piece of effective legislation that made this a little easier for me and for my pal that has emerged in the last half-century. Everything about the proposed replacement is cruelly inadequate, because that’s what it was designed to be. The pre-existing conditions protections are cheesecloth; the high-risk pools are guaranteed to bring us back to the days of generally unaffordable premiums. It’s still a tax bill dressed up as healthcare reform, which is like calling a crop subsidy a law enforcement measure.

And hand things back to the states? To Sam Brownback’s Kansas, or Scott Walker’s Wisconsin, or even my phantom companion’s Mississippi? Somehow, doing this, bringing millions of Americans back to the brink of a cliff they’d almost forgotten over eight years, makes those Americans more free? This is crazy. I turned on the hockey game.

Reading this made me hyperventilate. If my friend K. hadn’t known about the Obamacare pre-existing conditions bridge plan (that was in place before the regular policies kicked in), I have no doubt I’d be dead now.

Because when doctors keep telling you that you need surgery or you’ll die, and you tell them you don’t have insurance and all of a sudden they send you home (and they weren’t lying — one of my blogger friends died of pancreatitis), you begin to understand exactly how obscene this system is.

Your life is only as worthwhile as you can afford.

Medieval medical books could hold the recipe for new antibiotics

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A recipe for an eyesalve from ‘Bald’s Leechbook.’
© The British Library Board (Royal MS 12 D xvii)

Erin Connelly, University of Pennsylvania

For a long time, medieval medicine has been dismissed as irrelevant. This time period is popularly referred to as the “Dark Ages,” which erroneously suggests that it was unenlightened by science or reason. However, some medievalists and scientists are now looking back to history for clues to inform the search for new antibiotics. The Conversation

The evolution of antibiotic-resistant microbes means that it is always necessary to find new drugs to battle microbes that are no longer treatable with current antibiotics. But progress in finding new antibiotics is slow. The drug discovery pipeline is currently stalled. An estimated 700,000 people around the world die annually from drug-resistant infections. If the situation does not change, it is estimated that such infections will kill 10 million people per year by 2050.

I am part of the Ancientbiotics team, a group of medievalists, microbiologists, medicinal chemists, parasitologists, pharmacists and data scientists from multiple universities and countries. We believe that answers to the antibiotic crisis could be found in medical history. With the aid of modern technologies, we hope to unravel how premodern physicians treated infection and whether their cures really worked.

To that end, we are compiling a database of medieval medical recipes. By revealing patterns in medieval medical practice, our database could inform future laboratory research into the materials used to treat infection in the past. To our knowledge, this is the first attempt to create a medieval medicines database in this manner and for this purpose.

Bald’s eyesalve

In 2015, our team published a pilot study on a 1,000-year old recipe called Bald’s eyesalve from “Bald’s Leechbook,” an Old English medical text. The eyesalve was to be used against a “wen,” which may be translated as a sty, or an infection of the eyelash follicle.

Human white blood cells (in blue) take on Staphylococcus aureus bacteria.
Frank DeLeo, National Institute of Allergy and Infectious Diseases

A common cause of modern styes is the bacterium Staphylococcus aureus. Methicillin-resistant Staphylococcus aureus (or MRSA) is resistant to many current antibiotics. Staph and MRSA infections are responsible for a variety of severe and chronic infections, including wound infections, sepsis and pneumonia.

Bald’s eyesalve contains wine, garlic, an Allium species (such as leek or onion) and oxgall. The recipe states that, after the ingredients have been mixed together, they must stand in a brass vessel for nine nights before use.

In our study, this recipe turned out to be a potent antistaphylococcal agent, which repeatedly killed established S. aureus biofilms – a sticky matrix of bacteria adhered to a surface – in an in vitro infection model. It also killed MRSA in mouse chronic wound models.

Medieval methods

Premodern European medicine has been poorly studied for its clinical potential, compared with traditional pharmacopeias of other parts of the world. Our research also raises questions about medieval medical practitioners. Today, the word “medieval” is used as a derogatory term, indicating cruel behavior, ignorance or backwards thinking. This perpetuates the myth that the period is unworthy of study.

During our eyesalve study, chemist Tu Youyou was awarded the Nobel Prize in Physiology or Medicine for her discovery of a new therapy for malaria after searching over 2,000 recipes from ancient Chinese literature on herbal medicine. Is another “silver bullet” for microbial infection hidden within medieval European medical literature?

Certainly, there are medieval superstitions and treatments that we would not replicate today, such as purging a patient’s body of pathogenic humors. However, our work suggests that there could be a methodology behind the medicines of medieval practitioners, informed by a long tradition of observation and experimentation.

One key finding was that following the steps exactly as specified by the Bald’s eyesalve recipe – including waiting nine days before use – was crucial for its efficacy. Are the results of this medieval recipe representative of others that treat infection? Were practitioners selecting and combining materials following some “scientific” methodology for producing biologically active cocktails?

Further research may show that some medieval medicines were more than placebos or palliative aids, but actual “ancientbiotics” used long before the modern science of infection control. This idea underlies our current study on the medieval medical text, “Lylye of Medicynes.”

A medieval medicines database

The “Lylye of Medicynes” is a 15th-century Middle English translation of the Latin “Lilium medicinae,” first completed in 1305. It is a translation of the major work of a significant medieval physician, Bernard of Gordon. His “Lilium medicinae” was translated and printed continuously over many centuries, until at least the late 17th century.

The text contains a wealth of medical recipes. In the Middle English translation, there are 360 recipes – clearly indicated with Rx in the text – and many thousands more ingredient names.

As a doctoral student, I prepared the first-ever edition of the “Lylye of Medicynes” and compared the recipes against four extant Latin copies of the “Lilium medicinae.” This involved faithfully copying the Middle English text from the medieval manuscript, then editing that text for a modern reader, such as adding modern punctuation and correcting scribal errors. The “Lylye of Medicynes” is 245 folios, which equates to 600 pages of word-processed text.

I loaded the Middle English names of ingredients into a database, along with translations into modern equivalents, juxtaposed with relationships to recipe and disease. It is very time-consuming to format medieval data for processing with modern technologies. It also takes time to translate medieval medical ingredients into modern equivalents, due in part to multiple synonyms as well as variations in modern scientific nomenclature for plants. This information has to be verified across many sources.

With our database, we aim to find combinations of ingredients that occur repeatedly and are specifically used to treat infectious diseases. To achieve this, we are employing some common tools of data science, such as network analysis, a mathematical method to examine the relationships between entries. Our team will then examine how these patterns may help us to use medieval texts as inspiration for lab tests of candidate “ancientbiotic” recipes.

Word cloud from the Lylye of Medicynes.
Erin Connelly

In March, we tested a small portion of the database to ensure that the method we developed was appropriate for this data set. At present, the database contains only the 360 recipes indicated with Rx. Now that the proof-of-concept stage is complete, I will expand the database to contain other ingredients which are clearly in recipe format, but may not be marked with Rx.

We are specifically interested in recipes associated with recognizable signs of infection. With Bald’s eyesalve, the combination of ingredients proved to be crucial. By examining the strength of ingredient relationships, we hope to find out whether medieval medical recipes are driven by certain combinations of antimicrobial ingredients.

The database could direct us to new recipes to test in the lab in our search for novel antibiotics, as well as inform new research into the antimicrobial agents contained in these ingredients on the molecular level. It could also deepen our understanding of how medieval practitioners “designed” recipes. Our research is in the beginning stages, but it holds exciting potential for the future.

Erin Connelly, CLIR-Mellon Fellow for Data Curation in Medieval Studies, University of Pennsylvania

This article was originally published on The Conversation. Read the original article.

Americans can’t have nice health care

Scary surgery instruments

So the clear solution is to make them realize how stupid they are for wanting it! Additionally, neither the Democrats‘ Obamacare nor the Republicans’ Trumpcare can truly meet the unrealistic expectations of the American public. The public has four major expectations, which are inherently mutually incompatible. The public wants: (1) freedom to choose doctor and hospital;… Continue Reading →

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