Posts Tagged ‘healthcare’

Saudi health facilities force insured patients to pay with cash

November 25, 2017

Medical workers leave the hospital’s emergency department, in this April 27, 2014 file photo, in the Saudi capital Riyadh. (AFP)

RIYADH: The Council of Cooperative Health Insurance has said that health facilities do not have the right to demand payments from insured people, and that the punishment for such violation is a suspension.

The assurance came after repeated complaints that some health centers and hospitals refuse to register insurance claims and force patients to pay cash. The Health Insurance Council said that this procedure is illegal.
Yasser bin Ali Almuaarek, spokesman for the Council of Cooperative Health Insurance, said this constituted a violation of the council’s regulations and exposed the offender to punishments including suspension of the facility, according to an investigation published by Al-Eqtisadiah newspaper.
Almuaarek said that health facilities should adhere to the requirements of the accreditation of service providers, and should provide services promptly and observe the time limits for sending approvals to the insurance companies, as stated in article 90 of the executive regulations.
Almuaarek said that the number of insured people as per Nov. 22 was 11,992,727.

U.S. hospitals feeling the pain of physician burnout

November 21, 2017


By Julie Steenhuysen


1 / 17

Dr. Brian Halloran. a vascular surgeon at Saint Joseph Mercy Ann Arbor, shows the canned vegetables from his garden across from Saint Joseph Mercy hospital

Dr. Brian Halloran. a vascular surgeon at Saint Joseph Mercy Ann Arbor, shows the canned vegetables from his garden across from Saint Joseph Mercy hospital in Ypsilanti, Michigan, U.S., August 23, 2017. REUTERS/Rebecca Cook

By Julie Steenhuysen

ANN ARBOR, Mich. (Reuters) – Dr. Brian Halloran, a vascular surgeon at St. Joseph Mercy Ann Arbor, starts planning his garden long before spring arrives in southeast Michigan.

His tiny plot, located in the shadow of the 537-bed teaching hospital, helps Halloran cope with burnout from long hours and the stress of surgery on gravely ill patients.

“You really have to find the balance to put it a little more in perspective,” he said.

Hospitals such as St. Joseph Mercy Ann Arbor have been investing in programs ranging from yoga classes to personal coaches designed to help doctors become more resilient. But national burnout rates keep rising, with up to 54 percent of doctors affected.

Some leading healthcare executives now say the way medicine is practiced in the United States is to blame, fueled in part by growing clerical demands that have doctors spending two hours on the computer for every one hour they spend seeing patients.

What’s more, burnout is not just bad for doctors; it’s bad for patients and bad for business, according to interviews with more than 20 healthcare executives, doctors and burnout experts.

“This really isn’t just about exercise and getting enough sleep and having a life outside the hospital,” said Dr. Tait Shanafelt, a former Mayo Clinic researcher who became Stanford Medicine’s first chief physician wellness officer in September.

“It has at least as much or more to do with the environment in which these folks are practicing,” he said.

Shanafelt and other researchers have shown that burnout erodes job performance, increases medical errors and leads doctors to leave a profession they once loved.

For a graphic, click

Hospitals can ill afford these added expenses in an era of tight margins, costly nursing shortages and uncertainty over the fate of the Affordable Care Act, which has put capital projects and payment reform efforts on hold.

“Burnout decreases productivity and increases errors. It’s a big deal,” said Cleveland Clinic Chief Executive Dr. Toby Cosgrove, one of 10 U.S. healthcare CEOs who earlier this year declared physician burnout a public health crisis.


Hospitals are just beginning to recognize the toll of burnout on their operations.

Experts estimate, for example, that it can cost more than a $1 million to recruit and train a replacement for a doctor who leaves because of burnout.

But no broad calculation of burnout costs exists, Shanafelt said. Stanford, Harvard Business School, Mayo and the American Medical Association are working on that. They have put together a comprehensive estimate of the costs of burnout at the organizational and societal level, which has been submitted to a journal for review.

In July, the National Academy of Medicine (NAM) called on researchers to identify interventions that ease burnout. Meanwhile, some hospitals and health insurers are already trying to lighten the load.

Cleveland Clinic last year increased the number of nurse practitioners and other highly trained providers by 25 percent to 1,600 to handle more routine tasks for its 3,600 physicians. It hired eight pharmacists to help with prescription refills.

Atrius Health, Massachusetts’ largest independent physicians group, is diverting unnecessary email traffic away from doctors to other staffers and simplifying medical records, aiming to cut 1.5 million mouse “clicks” per year.

Insurer UnitedHealth Group, which operates physician practices for more than 20,000 doctors through its Optum subsidiary, launched a program to help doctors quickly determine whether drugs are covered by a patient’s insurance plan during the patient visit. It is also running a pilot program for Medicare plans in eight states to shrink the number of procedures that require prior authorization.

Similarly, Aetna Inc this year began a behavioral health program that eliminates prior authorization requirements for admission to some high-performing hospitals.


Experts define burnout as a syndrome marked by emotional exhaustion, cynicism and decreased effectiveness. Many burned out doctors cut back their hours to cope, and a disturbing number commit suicide.

A landmark 2015 Mayo Clinic study found that more than 7 percent of nearly 7,000 doctors had considered suicide within the prior 12 months, compared with 4 percent of other workers. About 400 a year go through with it.

Driving the burnout symptoms is the burden of data entry on clumsy electronic medical records systems that doctors must use to prove the quality of their care, said Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association.

Sinsky recently conducted an experiment in her own internal medicine practice in Dubuque, Iowa. She asked a staff member how many mouse clicks it takes to order and record a single patient’s flu shot in their electronic medical record. The answer: 32.

She has visited some practices where a doctor had to record flu shots for more than 1,000 patients because only the doctor was allowed to enter the order.

Such mandates reflect an overly strict interpretation of federal health reforms designed to encourage doctors to use electronic medical records, such as the 2009 Health Information Technology for Economic and Clinical Health Act that required doctors to demonstrate “meaningful use” of the systems.

“We have to recognize the exacting toll that the first generation of electronic health records have had on physicians,” Sinsky said. “I would identify it as one of the most important drivers of physician burnout.”

Pre-approval requirements from health insurers for many services and quality metrics built into Obamacare have added to doctors’ administrative duties.

“We’ve got this measurement mania. We’ve got to back off of that,” said Dr. Paul Harkaway, chief accountable care officer for Michigan’s St. Joseph Mercy Health System, a part of Trinity Health, a national not-for-profit Catholic healthcare system.

As a result of these requirements, primary care physicians spend more than half of their 11.4 hour workday performing data entry and other tasks, according to a September AMA/University of Wisconsin study published in the Annals of Family Medicine.

To manage, doctors often finish work at home in the evening, a part of the day known as “pajama time.”


Doctors’ suffering can take a direct toll on patients. In a 2010 study, Shanafelt and colleagues found that the more burned out a surgeon was, the more likely he or she was to report a major medical error. Other studies have shown that burnout drives up rates of unnecessary testing, referrals to specialists and hospital admissions.

When doctors quit, it costs an estimated $800,000 to $1.3 million in recruitment, training and productivity costs, depending on the specialty.

Even when physicians don’t leave, they can contribute thousands of dollars in costs each year “just as a matter of inefficient functioning,” said Dr. Colin West of the Mayo Clinic.

The trend has medical malpractice experts concerned. CRICO, the malpractice carrier for Harvard University’s two dozen affiliated hospitals, recently had to settle a handful of cases because doctors were too burned out to fight, even though CRICO believed it could win.

“The clinician just wanted it to go away,” said Dr. Luke Sato, CRICO’s chief medical officer. Sato estimates that an average breast or colorectal cancer malpractice case might cost $750,000 to $1 million to settle.

The crisis has Harkaway worried for his colleagues in Michigan, and for his profession.

“Working with doctors every day, you see it,” he said. “They are just beat down.”

(Reporting by Julie Steenhuysen; Editing by Michele Gershberg and Editing by Edward Tobin)

U.S. seniors struggle more to pay for healthcare compared to other countries

November 16, 2017
By Steven Reinberg, HealthDay News  |  Nov. 15, 2017 at 9:57 PM

WEDNESDAY, Nov. 15, 2017 — A new report finds the availability of health care for U.S. seniors lags behind that of other affluent nations.

Access to insurance isn’t an issue, because all Americans 65 and older are covered by Medicare. But America’s seniors are still sicker than the elderly in other countries — and are more likely to go without essential care because they can’t afford it, according to the Commonwealth Fund study.

“Our Medicare is not as generous as comparable insurance in other countries,” fund President Dr. David Blumenthal said during a media briefing on Tuesday.

In other countries, government health insurance is not restricted to the elderly, but covers everyone, he said.

The United States is complacent about the value and benefits associated with Medicare, even though it’s a universal system, Blumenthal said.

“We do know that we, as a country, do tolerate higher levels of inequality. That’s most evident in the fact that we underinvest, compared to other countries, in social services and overinvest, despite the lack of generosity of our insurance, in health care,” he said.

Providing more social services to the elderly might help reduce the inequality of care, Blumenthal said.

For the study, researchers surveyed older adults about their health care. Participants came from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.

Almost one-quarter of U.S. seniors didn’t go to a doctor in the past year when sick or they didn’t get a recommended test or fill a prescription because they couldn’t afford it.

In France, Norway, Sweden and the United Kingdom, no more than 5 percent of older adults skipped care because of costs, the researchers found.

In the United States, 22 percent of seniors spent $2,000 or more on out-of-pocket costs during the past year. The only country with higher out-of-pocket costs was Switzerland, with 31 percent spending more than $2,000 out of pocket.

Among all the other countries, less than 10 percent of seniors spent $2,000 or more, researchers found.

Among U.S. seniors, 25 percent said they worried about having the money to buy food or pay rent or bills for heat or electricity or medical care.

However, in France, the Netherlands, New Zealand, Norway, Switzerland, Sweden and the United Kingdom, only 10 percent or less said they had these concerns.

Seniors in many countries who suffered from several chronic health problems or had trouble with the basic activities of daily living reported being dissatisfied with the quality of their care.

For example, in Australia, 41 percent were somewhat or not at all satisfied, compared with 26 percent in the United States and 21 percent in Switzerland, the country rated the best in satisfaction.

Cost was also a concern for the sickest. In the United States, 31 percent skipped health care due to costs, compared with 2 percent in Sweden. Additionally, almost a third of the sickest U.S. seniors worried about having enough money for meals, rent or other bills, researchers reported.

The sickest seniors in other countries struggled as well, with about 25 percent of those in Australia and Germany also saying that they worried about paying for food, rent or other bills.

Many of these seniors also suffered from anxiety or depression, which can lead to poorer health and higher costs, Blumenthal said. Social isolation was also a problem faced by a number of seniors, particularly in European countries, the study found.

Access to care, especially after hours and on weekends, is another challenge seniors face.

Fifteen percent of U.S. seniors and 11 percent of Canadian seniors went to the emergency room for a condition that could have been treated by a regular doctor or clinic had one been available. In other countries, that figure is 8 percent or less, the researchers said.

U.S. doctors did well when it came to counseling seniors on diet, exercise and the risk of falling. Only doctors in Australia and France were similarly likely to discuss falls with their patients, the researchers found.

Dr. Ken Brummel-Smith is professor emeritus of geriatrics at Florida State University College of Medicine, and a spokesman for Physicians for a National Health Program. He said that providing more home care, social services and after-hour doctor and clinic times could help improve the care of the elderly.

“What older people really need are the support systems to manage themselves,” Brummel-Smith said. “Everyone wants to live independently if possible, but we aren’t set up to do that.”

The report was published Nov. 15 in the journal Health Affairs.

More informationFor more on elder care, visit the U.S. Department of Health and Human Services.

Democrats, GOP Spar Over Who Is to Blame for Rising Health-Insurance Premiums

November 9, 2017

This week’s election results suggest political challenges for Republicans on health care one year before 2018 midterm vote

Virginia Governor-elect Dr. Ralph Northam after his decisive victory. PHOTO: WIN MCNAMEE/GETTY IMAGES

The day before Halloween, Dorie Lawson learned her health insurance premiums would jump by 60% next year to nearly $3,000 a month.

Now she is looking for someone to blame. Her insurer, Blue Cross Blue Shield of Wyoming, cited uncertainty about health policy in Washington, especially regarding federal payments to insurers, in raising its premiums this way.

Ms. Lawson, of Sheridan, Wyo., wonders if President Donald Trump, who in October decided to end those subsidies, is at least partly to blame.

“Trump had that executive order on health care, and I think it’s made it worse for us,” said Ms. Lawson, adding she is unsure how to pay for the premium increase. “We were up all night feeling like we got punched. We’re figuring out what we’re going to do.”

The battle in Washington over the fate of the Obama-era law is now starting to hit Americans’ pocketbooks as the ACA’s open enrollment seasons begins, allowing consumers to choose their plans for 2018. Millions of people who don’t get subsidies are seeing steeper costs, sparking a battle between Democrats and Republicans over who gets the blame.

Tuesday’s election results suggest the politics of health care may be tilting against Republicans for the first time in years. Democrats have long paid a political price for the ACA’s unpopularity, losing elections since 2010 after the law was passed through last year, when the health law’s problems factored heavily into the Republican message.

But this week, Virginia voters cited health care in exit polls as an important reason for delivering the governorship to Democrat Ralph Northam, while a ballot initiative in Maine to expand the state’s Medicaid program won decisively. That follows the GOP’s failure to repeal the ACA and low public approval for the alternatives it offered.

If those developments signal a broader shift in the landscape, it could have a big impact on the 2018 midterm elections, where all seats in the House and a third in the Senate are up for grabs. Adding an unpredictable element to the mix, many voters in states that supported Mr. Trump will face some of the biggest increases.

In Deaf Smith, Texas, for example, a 40-year old single individual who earns too much for federal aid will see premiums jump 87%—from about $290 to $540—according to a Kaiser Family Foundation analysis of prices for a popular, midprice health plan. Only people who make less than 400% of the poverty level—about $48,000 in most states this year—are eligible for federal aid.

In Clinton, Iowa, premiums will rise from $288 to $781, an increase of 171%, for the same plan.

According to an October poll by The Wall Street Journal and NBC News, 50% of Americans would blame Republicans if health-care costs rise and people lose coverage, while 37% would blame Democrats.

More Health-Policy News

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  • U.S. Must Do More to Combat Opioid Abuse, Panel Says November 1, 2017
  • Health Premiums to Rise, Trump Administration Says October 30, 2017
  • Trump Administration Relaxes Medical Privacy Rule for Overdoses October 27, 2017

Both sides have begun positioning themselves for the coming campaign. About 40 liberal-leaning groups announced recently they would join forces to target Republicans on health care in 2018.

In the Virginia governor’s race, Mr. Northam ran ads spotlighting his career as a pediatrician and pledging to “provide access to health care for all Virginians, not take it away.” He criticized Mr. Trump for ending payments to insurers that subsidize low-income consumers.

Mr. Trump, for his part, has begun pointing the finger at Democrats. “As usual, the ObamaCare premiums will be up (the Dems own it), but we will Repeal & Replace and have great Healthcare soon after Tax Cuts!” he tweeted recently. A new Republican ad blames rising premiums on the ACA, blaming Democrats for blocking GOP plans to overhaul it.

The conflict is also playing out within parties. Nevada GOP Senate candidate Danny Tarkanian tweeted in September that incumbent Sen. Dean Heller (R., Nev.) was “deceitful” for backing a bill that would have cut Medicaid after saying he wouldn’t. Democrats have also run ads hammering Mr. Heller for supporting ACA repeal.

Mr. Heller has responded by seeking to position himself in the middle, saying that “Obamacare clearly isn’t the answer—but doing nothing isn’t the answer either.”

Mr. Trump in early October stopped paying billions of dollars to insurers under an ACA program that offset subsidies received by some lower-income consumers to help with out-of-pocket medical costs. Some states had let insurers file higher rates for 2018 in case the payments ceased, while others moved quickly following Mr. Trump’s action to let insurers raise rates.

Sen. Patty Murray (D., Wash.) and Sen. Lamar Alexander (R., Tenn.) offered a bill restoring the payments to insurers for two years, while giving states more say in implementing the ACA. Mr. Trump opposes the deal, but if it passes in December, as backers hope, consumers would start getting notices about rate relief from insurers about a month before the 2018 election.

Sen. Patty Murray (D., Wash.) (left) and Sen. Lamar Alexander (R., Tenn.)

“The people who are forgotten are the nine million who don’t get insurance on the job or federal government and don’t get subsidies,” said Mr. Alexander. “They’re getting hammered.”

Some Republicans support the Alexander-Murray proposal. Others are ramping up efforts to repeal the ACA’s requirement that most people have health coverage or pay a fine, which may be included in a tax-overhaul bill Congress is currently working on.

‘The people who are forgotten are the nine million who don’t get insurance on the job or federal government and don’t get subsidies.’

—Sen. Lamar Alexander (R., Tenn.)

The individual insurance market, where people buy private coverage if they don’t get it through work or programs such as Medicare or Medicaid, remains largely stable for now. But analysts expect that next year, the gulf between people who get subsidies and those who don’t will widen.

Many of the roughly 8.7 million lower-income people who receive subsidies will see their financial-assistance rise to offset premium increases.

But the roughly 7 million middle-income consumers who make too much to get subsidies or are in plans that aren’t eligible for the aid may see their premiums jump. Republicans say that is because the ACA isn’t working and insurers are fleeing the market; Democrats say the GOP is driving up premiums by undermining the ACA and creating uncertainty.

“There is unquestionably a growing divide in affordability between lower-income people who qualify for premium subsidies and middle-income people who do not,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation.

AnnMarie McIlwain, a patient advocate in Summit, N.J., pays $1,087 a month for a family policy, and her premiums next year are going up 39%. With their deductible, the family’s annual health costs could surpass $20,000.

“I find it outrageous. I think there’s going to be a huge outcry,” said Mrs. McIIwain, 56. “They have gone up year over year, but never like this.”

Write to Stephanie Armour at

New study explains why US health care spending increased $1 trillion

November 9, 2017
November 7, 2017
Credit: CC0 Public Domain

A new study finds that the cost of health care in the United States increased nearly $1 trillion from 1996 to 2013 and measures the causes behind this immense growth.

The study, published today in JAMA, reveals that price and “intensity” (variety and complexity) of services accounted for 50% of the increase.

“Part of the reason we spend more on health care each year is the nation’s growing and aging population,” said Dr. Joseph Dieleman of the Institute for Health Metrics and Evaluation at the University of Washington and lead author of the study. “But factors relating to the health system, such as increased price, intensity, and utilization, are driving most of the  increase.”

Five factors contribute to the rise in  in the US: (1) more people; (2) an aging population; (3) changes in disease prevalence or incidence; (4) increases in how often people use ; and (5) increases in the price and intensity of services. This research measures the impact of these different drivers on the total increase in health care spending and for the increases caused by specific health conditions and types of care.

An in-depth data visualization is available at:

The study covers health care spending for individuals and includes spending on inpatient care, outpatient care, nursing facilities, emergency departments, dental care, and prescribed pharmaceuticals. It also includes funding from all payers, such as private insurance, Medicare, Medicaid, and households’ own spending.

“When we added up all the health conditions, increasing population size led to a 23% increase in ,” Dr. Dieleman said. “People getting older led to a 12% increase in spending, and increases in price and service intensity, that is the variety and complexity of services, led to a 50% increase in spending.”

Most importantly, increases in spending also vary dramatically depending on people’s conditions and types of care, such as inpatient, outpatient, pharmaceuticals, and others, he said. Health care spending on  increased a dramatic 85% between 1996 and 2013, largely due to increasing use of services. Spending on inpatient care grew 59% because of price increases and service intensity.

“These findings offer insight into why the US spends so much on  care,” said Dr. Jay Want, executive director of the Peterson Center on Healthcare, which funded the study. “Increased  spending is driven more by how care is priced and delivered to patients than by the population’s size or age. The research suggests the need for more efforts to address those forces that control pricing.”

 Explore further: How much money is spent on health care for kids, where does it go?

Britain’s National Health Service (NHS) in ‘toughest ever financial situation’, says outgoing trust boss — Patients left in danger of “safety risks”

October 29, 2017

SKY News

Hospitals are pushed to their limits and the NHS is in the toughest financial situation since it was created, says one trust boss.

NHS staff push a bed down a hospital corridor
Image:Next year the NHS budget will rise by just 0.7%, a real-terms cut

The NHS is facing the most difficult financial circumstances in its history and may not be sustainable without a long-term increase in funding, one of its most experienced executives has told Sky News.

Peter Homa stood down as chief executive of Nottingham University NHS Hospital Trust this week after a 40-year career in the NHS that began when he worked shifts as an operating theatre porter.

In his final interview he offered a stark assessment of the challenges facing the health service as it tries to meet rising demand while enduring the tightest financial squeeze in its history.

“Financially, it is extremely challenging,” he said.

“Nottingham, like 97% of hospital trusts in the UK, is in deficit. We are on track to hit our savings target but it is extraordinarily difficult.

Peter Homa is retiring after a 40 year career in the NHS
Image:Peter Homa is retiring after a 40-year career in the NHS

“I have been a chief executive of NHS organisations for 27 years and it is fair to say that this is the toughest financial circumstances I have known.

“It is also objectively true to say it is the toughest in NHS history.”

Mr Homa, who will take up a role as chairman of the NHS Leadership Academy in retirement, said increasing demand and expectations of care were hugely demanding.

“It is a combination of a really tough financial environment, alongside the quite proper requirement to deliver agreed standards of care.

“Having to achieve exquisitely tight financial targets while improving the quality of care is extremely challenging, it is the toughest it has ever been.”

Hospital trolleys lined up in a corridor

Video:Oct 12: NHS facing crisis over shortage of GPs and threat of major flu outbreak

His assessment bears out the national picture.

Demand for NHS services is rising at around 4% a year but funding has fallen behind, rising at the slowest rate since it was founded in 1948.

The pressure has seen the NHS nationally fail to hit any of its main targets in each of the last 12 months, including the bellwether of 95% of A&E patients being seen within four hours.

Next year the NHS budget will rise by just 0.7%, a real-terms cut that means trusts across the country will again be asked to make savings.

In Nottingham the financial squeeze has seen a trust that ran at a surplus until 2014-15 pushed it into deficit.

Mr Homa has been required to make savings of more than £40m in each of the last four years, and the trust is on course to cut another £40m this year, taking the total to more than £200m in five years.

Demand has continued to rise however, and the trust has struggled to hit its targets.

In the year to date, 83.2% of patients have been seen within four hours.

Mr Homa’s final months in the job have been spent helping plan for what many fear will be a hugely challenging winter across the NHS.

He says that “winter pressure” has become year-round pressure with no appreciable drop-off in late spring and early summer.

Queens Medical Centre A&E department in Nottingham is experiencing demand far greater than it was designed for, and is currently seeing just over 83% of patients within four hours.

Mr Homa is confident the service is better prepared than in previous years, largely because of greater co-operation with social and community care providers.

“Winter is is a complex interlocking jigsaw and the reason I am more confident this year is that we have some excellent work across the wider social care sector. We will be able to do a better job because of the collaboration.

“Our A&E was designed in the 1960s and built in the 1970s for a maximum of 350 patients a day.

“We regularly see 500 people a day and last Monday saw 700, the highest ever.

“And it is not just the number of patients, but they are elderly and they have complex needs, and we need to make sure that they are all expertly attended to.”

His assessment, born of frontline experience, is particularly valuable as hospital managers have become reluctant to speak out since two chief executives of poorly performing hospital resigned last month under pressure from regulators.

A survey has found many nurses are stressed or burnt out

Video:September: Patients ‘dying alone’ because of lack of NHS staff

He offers a curt assessment of the re-structuring imposed by Andrew Lansley’s 2012 Health and Social Care Act: “If it didn’t exist you wouldn’t invent it” – but is positive about the attempt to work around it using sustainability and transformation plans, or STPs.

These are intended to make health providers in local areas work together more closely, putting the patient rather than the institutions first.

“What experience has taught me, by which I mean my mistakes, is that if we focus on the patients we will get it right,” says Mr Homa.

But he is pessimistic about the long-term funding picture, and says the Government should commit to increasing the share of GDP spent on healthcare.

“The future is extremely challenging on the current funding model,” he says.

“The Government faces profound political questions that have to be addressed in terms of what share of GDP they spend.

“We know the UK has slipped down the league table in terms of share, and my own view is that the NHS needs sustained improvements in funding. Without it the future is really challenging.”

Nurses protesting against the 1% cap on annual pay rises for most NHS staff
Image:Workers have protested against the 1% cap on annual pay rises for most NHS staff

He would support a pay rise for staff – who are ever-more stretched to keep up with demand – but warns the NHS cannot afford to pay for it from existing funds without drastic cuts to services and staff.

“Our staff and public sector workers in general have served the country without an increase in pay for a long time and the deserve a rise, but any increase must be properly funded.

“We could not fund any pay rise from within the NHS, we are already stretched. It would be extraordinarily difficult.

“Here in Nottingham it would mean on top of the £40m savings we are already making we would have to find £30m more.

“We’d have to do less, we’d have to lose staff, it would be totally impossible in my view.”

Jeremy Corbyn discusses what Labour would do for the NHS

Video:August: Corbyn’s three ways to save the NHS

It is the NHS staff that bring him to sound his most optimistic note when looking back on a career that has seen profound change in the health service.

When Mr Homa began his career in the 1970s the fax machine was a cutting-edge development.

Today Nottingham offers robotic operations and advanced radiography, but he says the commitment of the people has not changed: “What is undiminished is the passion and absolute determination of staff to do the very best they can for patients, which is why it has been a privilege to serve the NHS in Nottingham and elsewhere.”

Health Care Back on Congress’s Front Burner

October 16, 2017

Trump’s move to stop subsidy payments ratchets up pressure for a bipartisan deal

WASHINGTON—The Senate this week will grapple with President Donald Trump’s decision to stop making subsidy payments to health insurers, with lawmakers seeking a deal that would keep the money flowing while Republicans try to fold in conservative-oriented health-care priorities.

It remains unclear whether a package could emerge that attracts support from a critical mass of senators and also from House Republicans. That could be put to the test quickly, as Sens. Lamar Alexander (R., Tenn.) and Patty Murray (D., Wash.) are expected to introduce a plan within days and Sen. Ron Johnson (R., Wis.) unveils his own, more-conservative-leaning version.

The result, driven by unexpectedly far-reaching moves by Mr. Trump on health care last week, could be a resumption or even escalation of the legislative battle that unfolded during Republicans’ attempts to repeal the 2010 Affordable Care Act. It comes as insurers press some state and federal officials to let them reset their rates for 2018 in light of the halting of the subsidies, while one state, Oregon, already has told insurers to jack up rates for their most popular plans.

On Monday, Mr. Trump is meeting with Senate Majority Leader Mitch McConnell (R., Ky.) to discuss budget and tax issues, with health care also a possible topic.

Mr. Trump met Saturday with Mr. Alexander, Sen. Lindsey Graham (R., S.C.) said on CBS , and he encouraged Mr. Alexander to pursue his deal, Mr. Graham said.

The “cost-sharing reduction” payments ended last week by Mr. Trump help insurers offset subsidies to low-income Americans. Many Republicans, fearing chaos in the insurance market if the payments stop, want to extend them as long as that is accompanied by moves such as relaxing regulations on some insurance plans.

“I think Congress should pass that short-term extension” of payments, Sen. Bill Cassidy (R., La.) said Sunday on Fox. “We absolutely have to think about that family around the kitchen table, which is why we should pass them”—but only if they are packaged with provisions that he said would lead to lower premiums.

Democrats say the Republican approach to lowering premiums involves stripping important consumer protections, allowing for insurance policies that provide insufficient coverage. Healthier, younger Americans may have access to lower premiums under the GOP approach, they say, but older and sicker consumers would see their costs go up.

Sen. Chris Murphy (D., Conn.) said Mr. Trump’s decision to end the payments was retaliation for Republicans’ inability to repeal the ACA. “This is the equivalent of health-care arson,” Mr. Murphy said on Fox. “He is literally setting the entire health care system on fire just because he is upset that Congress won’t pass a repeal bill supported by 17% of the public.”

Some Republicans say they are less concerned with the payments themselves than the fact that the Obama and Trump administrations have been making them without an appropriation from Congress, which they say is unconstitutional.

This week’s most closely watched event will likely be the unveiling of the Alexander-Murray plan, which the two senators have been discussing for months. In exchange for extending the insurer payments, the bill would give states permission to obtain waivers under the ACA, paving the way for more variation in insurance plans, according to people on Capitol Hill.

Mr. Johnson, for his part, is working on legislation that includes additional conservative measures, such as expanding the use of health-savings accounts and delaying the enforcement of the mandate that most employers provide insurance.

Mr. Johnson said he is seeking a bill House Republicans would accept. “We can do stuff in the Senate, but if it dies in the House, we haven’t done much,” he said in an interview.

Mr. Johnson said he recognized that many Republicans are hesitant to fund the payments. But ending them could result in higher premiums for consumers and more money spent by the government, which would have to provide larger subsidies to certain consumers, he said.

“Insurance companies get paid either way,” Mr. Johnson said, and he is “trying to find that sweet spot that will fund the cost-sharing reductions” and “restrain the growth in premiums.”

Conservative House Republicans have indicated any support for continuing the payments would depend upon significant concessions from Democrats on curbing the ACA.

If lawmakers reach a bipartisan deal on health care, it isn’t clear whether it would be voted on as a standalone bill or as part of complex negotiations looming in December.

The government’s current funding expires after Dec. 8, and other hot-button issues could get wrapped into the end-of-year discussions, including how to handle illegal immigrants brought to the country by their parents at a young age.

Democrats will have leverage in those talks because the spending bill, needed to avert a government shutdown, would need 60 votes to clear the Senate, where Republicans hold a 52-48 advantage.

For now, many in the health industry are reacting with alarm to the prospect of the subsidy payments ending. A diverse coalition representing health plans, doctors and businesses sent a letter to Congress Saturday asking lawmakers to “act immediately” to restore the payments.

In one example of the immediate impact of halting the payments, Oregon ordered insurers in the state who sell on the ACA’s exchanges to increase premium rates for 2018 for the most popular plans by 7.1%.

While some insurers had already filed rates for higher premiums with the expectation the payments might be discontinued, insurers in more than a dozen states filed rates that didn’t take into account the possibility. Some of those insurers are now saying they need to raise rates by 20% or more for next year, but the federal deadline for filing has already passed.

Before announcing late Thursday he would cut off the payments, Mr. Trump issued an executive order designed to bolster various alternative insurance arrangements, which are less regulated than traditional policies. Mr. Trump has he would continue using administrative action to try to dismantle the ACA, and Democrats are seeking ways to fight back, from litigation to legislation.

Sen. Susan Collins of Maine, a centrist Republican, said on ABC that for a deal on payments to work, “Democrats are going to need to step up to the plate and assist us.”

She added, “I’m very disappointed in the president’s actions this past week…But Congress needs to step in and I hope the president will take a look at what we’re doing.”

—Brody Mullins and Eric Morath contributed to this article.

Write to Stephanie Armour at and Kristina Peterson at

In Start to Unwinding the Health Law, Trump to Ease Insurance Rules

October 12, 2017

Directive is expected to expand the sale of less-expensive plans with fewer benefits

President Donald Trump is planning to sign an executive order Thursday to initiate the unwinding of the Affordable Care Act, paving the way for sweeping changes to health-insurance regulations by instructing agencies to allow the sale of less-comprehensive health plans to expand.

Mr. Trump, using his authority to accomplish some of what Republicans failed to achieve with their stalled congressional health-care overhaul, will direct federal agencies to take actions aimed at providing lower-cost options and fostering competition in the individual insurance markets, according to a Wall Street Journal interview with two senior White House officials. The specific steps included in the order will represent only the first moves in his White House’s effort to strike parts of the law, the officials said.

By boosting alternative insurance arrangements that would be exempt from some key ACA rules, the change would provide more options for consumers. But health-insurance experts say it could raise costs for sicker people by drawing healthier, younger consumers to these alternative plans, which could be less expensive and offer fewer benefits.

The executive order—which Mr. Trump plans to unveil in a signing ceremony in the Roosevelt Room Thursday, surrounded by cabinet officials and employer representatives—will aim to expand access to plans that let small businesses and possibly individuals band together to buy insurance. It will also lift limits on the sale of short-term insurance, which provides limited coverage and often appeals to healthier people. And it will seek to expand the ways in which workers use employer-funded accounts to buy their own insurance policies.

It will be months, rather than weeks, for even the most simple changes in the executive order to take effect, and the order leaves key details to the Labor Department, in particular, to determine after a formal rule-making process, including the solicitation of public comment.

But taken together, the instructions will amount to a reversal of the broad ACA approach, which seeks to guarantee that insurance policies offer a minimum level of benefits to all consumers regardless of their health history. Mr. Trump and other Republicans argue that such rules must be relaxed to bring down premiums, especially for healthier people who have seen costs rise under the ACA.

The order also will set the stage for potential future action, as Mr. Trump weighs whether to stop enforcing the ACA requirement that most Americans obtain insurance, for example, and whether to keep making payments that let insurers subsidize lower-income consumers.

And in a surprising move, the White House officials also said Wednesday night that the order would direct agencies to study and issue a report on federal and state policies that could contribute to rising health costs—including, potentially, the impact of health-care provider consolidation.

Health analysts predicted that Thursday’s order could tempt critics to pursue legal challenges, opening a new front in the health-care battle. But the order is likely to leave much of the implementation details to agencies, senior White House officials said Wednesday, and they said they didn’t believe the order could be litigated.

The action marks the biggest change to health care since the November election. The ACA, also called Obamacare, made sweeping changes to health insurance pricing that made insurance newly accessible for lower-income and sicker Americans, but also resulted in market turbulence and higher premiums for healthier and middle-income peo ple, in particular.

Republicans’ effort to repeal the ACA collapsed in Congress last month, and Mr. Trump hasn’t hidden his displeasure at GOP leaders for that failure or his desire to step into the gap. The White House officials said Wednesday night that the order was specifically crafted in the context of the failure of the repeal bid.

“Since Congress can’t get its act together on HealthCare, I will be using the power of the pen to give great HealthCare to many people – FAST,” Mr. Trump tweeted this week in signaling his intent to issue the executive order.

Democrats, however, warned the order could cause turbulence in the insurance market and overlooks the complexity of the health-care system. “It has the potential to be very disruptive,” said Rep. John Yarmuth of Kentucky, the top Democrat on the House Budget Committee. “I don’t think the insurance companies are prepared to actually deal with that.”

The order will direct the Labor Department to take steps that speed the way for small businesses, and possibly individuals, to band together in arrangements called association health plans. These insurance plans would be exempt from some regulations, such as the requirement that they offer a specific set of benefits and they would likely attract those with limited health needs.

The final decision about how far to expand the definition of an association and its members will be left to the agency, after a period of public comment, the two White House officials said. The officials said they supported a more expansive view of who might be considered to be eligible to sign up, but weren’t prescribing a specific legal definition—a significant factor in determining the impact of the change on insurance markets.

Supporters say such health plans can costs less, since they wouldn’t be subject to as many regulations. But critics say that leaves consumers at risk if they wind up with expensive health conditions that aren’t covered.

Currently, these self-insured health plans are typically led by trade groups that are subject to state regulation, but agency moves following the Trump order would free them from many of those rules.

In another move, the executive order will call for expanded access to short-term health plans whose availability was curtailed by the Obama administration. These plans have more flexibility than others allowed under the ACA, such as an ability to refuse coverage to people with pre-existing conditions.

The Obama administration limited these policies to less than three months, with no ability to renew them after that time because of concerns they were siphoning off healthier people from the ACA marketplaces.

As with association plans, supporters say short-term policies provide more options and carry lower premiums, while critics say they would attract the healthy and leave higher-risk people in more traditional plans that would become more costly since the population would be older and sicker.

Finally, the order will direct agencies to rescind an Obama-era guidance on employer-funded accounts that workers use for medical costs. Employees who have these accounts, called health reimbursement arrangements, will likely be allowed to use them to buy their own insurance plans, something that is now forbidden.

The Obama administration blocked the pretax dollars from being used to buy such plans because of concerns that would prompt employers to stop offering coverage of their own.

—Kristina Peterson contributed to this article.

Write to Louise Radnofsky at, Stephanie Armour at and Anna Wilde Mathews at

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Donald Trump, the President Without a Party

October 9, 2017

Estrangement from Republican leaders clouds the White House’s agenda

President Trump walked to board Marine One at the White House on Saturday.
President Trump walked to board Marine One at the White House on Saturday. PHOTO: SHAWN THEW/POOL/ZUMA PRESS

Increasingly, Donald Trump is a president without a party.

With virtually no Republican votes to spare in the Senate, where his agenda hangs in the balance, he has nonetheless become estranged from two key figures in his own party. First it was John McCain of Arizona, over his defiance of the president on health care. Next it was Bob Corker of Tennessee, who feuded with the president in a remarkable weekend of exchanged insults.

As it happens, Mr. McCain is chairman of the Senate Armed Services Committee; Mr. Corker is chairman of the Senate Foreign Relations Committee. Thus, the president is alienated from the two most important Senate figures on national security at a time when two critical national-security issues are coming to a boil: the fate of the nuclear deal with Iran and the increasingly dangerous standoff with North Korea.

Meanwhile, Mr. Trump backed the losing candidate in a Republican primary runoff in Alabama, finding himself trapped between the party establishment whose choice he supported and the social conservative foot soldiers who backed Roy Moore, the candidate who actually won.

Now, Mr. Trump’s once and perhaps current political guru, Steve Bannon, has set out to attack much of the rest of the Republican caucus in the Senate. He’s also gunning for the entire GOP congressional leadership, with which the president is himself increasingly disillusioned.

President Trump defied the Republican party this week by striking a deal with Democrats in Congress on raising the debt ceiling, keeping the government running and funding hurricane relief. The WSJ’s Gerald F. Seib explains whether this signals Trump will be more independent in the coming weeks. Photo: AP

After a conversation with Mr. Bannon in recent days, Robert Kuttner of the American Prospect summarized his agenda this way: “Bannon’s current obsession is to blow up Senate Majority Leader Mitch McConnell and Republican Senate incumbents whom he regards as hostile to his brand of nationalism.”

Mr. Trump has tried to adjust to this growing estrangement from leaders of his own party by opening the door to cooperation with Democrats on immigration and health care. But after seemingly striking a deal with Democrats to protect the legal status of so-called Dreamers—young immigrants brought here illegally as youths—he plotted strategy over how to follow through on that agreement with a group of Republican senators over a White House dinner last week.

What emerged was a list of demands that may well blow up any pending immigration deal. To get the Dreamers deal Democrats want, Mr. Trump called for, among other things, funding for a wall he wants along the Mexican border, new restrictions on those seeking asylum in the U.S. and punishment for localities that declare themselves “sanctuary cities.”

Those principles surely are negotiable. Still, they seem to leave Mr. Trump trapped in a kind of immigration no-man’s-land, between Democrats wanting a Dreamers fix and Republicans hoping to use that fix as a lever to push through broad immigration changes they’d like to make.

The question is: Where is this all supposed to lead?

There is an answer to that—in the long run. Mr. Trump would like to lead, and Mr. Bannon would like to create, a Republican Party different from the one that exists. It would be a party molded in the Trump image: nationalist, skeptical of immigration and trade agreements, dubious about the virtues of diplomacy and international negotiations, with economic strategies skewed to help workers in traditional American industries.

After all, Mr. Trump has said on several occasions—most notably at a conservative conference in February—that he wants the GOP to be the party “of the American worker.”

There are three problems with that vision, though. First, that party doesn’t exist today. The current version of the GOP was built largely by merging the interests of the business community with the agenda of social conservatives. Neither of those groups would win top billing in the vision for a new, Trump-inspired party.

The second problem is that it isn’t at all clear that such a new Republican Party would, in fact, be a majority party. There are disaffected people loitering in both current major parties—disgruntled blue-collar workers, fearful middle-class Americans, trade skeptics, those who feel culturally alienated from the current Democratic establishment—who are drawn to such a vision.

But ultimately, Mr. Trump failed to win the popular vote even as he won the presidency in 2016, and he has never come close to winning majority approval for the job he’s doing as president.

The third problem is that, while waiting for that Republican Party to emerge, Mr. Trump confronts the job of governing today. The current party has just 52 members in the Senate, and, as noted, Mr. Trump doesn’t have the loyal support of all of them. Mr. Bannon and his allies are threatening to challenge other Republican incumbents in primary elections next year, which won’t exactly keep those targeted at his side.

Meantime, Mr. Trump hasn’t forged reliable tactical alliances with enough Democrats to make up the difference. Which leaves him a leader in search of reliable followers.

Write to Gerald F. Seib at

Trump says he called Schumer on health care — Even a temporary deal would be good

October 8, 2017