Republicans still short of votes to pass U.S. healthcare overhaul

By Richard Cowan and David Morgan

Republicans in the U.S. House of Representatives said on Tuesday they were closer to agreeing on a reworked bill to overhaul the nation’s healthcare system but still lacked the votes to pass it, as President Donald Trump pressed lawmakers for a vote.

The White House has been pressuring House Republicans to push ahead with legislation to repeal and replace the Affordable Care Act, commonly called Obamacare, after a first effort failed in March in a stunning setback for the Trump administration.

“I think it’s time now” for a healthcare vote, Trump said at the White House on Tuesday.

But Republican leaders are struggling to balance the concerns of moderates, who want to protect those with pre-existing medical conditions from being shut out or penalized by insurers, and of conservatives who want to ease what they see as Obamacare’s heavy burden on the economy.

Representative Mark Meadows of North Carolina, who heads the staunchly conservative House Freedom Caucus that helped block passage of the first healthcare bill, said Republicans were still “a handful of votes away.”

The current bill would allow states to opt out of Obamacare provisions that force insurers to charge sick and healthy people the same rates. That is seen as a concession to the Freedom Caucus, which has endorsed the new measure.

But Trump insisted in an interview this week that the protections for those with pre-existing conditions would remain.

“It’s close. It’s close. We’re getting there,” said Representative Tom MacArthur of New Jersey, a moderate Republican who brokered the deal that revived the healthcare legislation.

“I know this is difficult and I know people are worried.”

Republicans have long vowed to repeal Democratic former President Barack Obama’s 2010 healthcare restructuring, arguing that the law, which allowed some 20 million Americans to gain healthcare insurance, was too intrusive and expensive.

During his 2016 presidential campaign, Trump also vowed to get rid of it.

He made its repeal the first major legislative item of his presidency, investing early political capital, only to see the bill he backed torpedoed by his own party.

This time, the White House appears to be taking more of a low-key approach.

“I think it’s been quieter. I think it’s been more bottom-up-driven from a member’s standpoint,” said Republican Representative Mark Sanford of South Carolina.


Republicans, however, remain divided over key aspects of the bill, with some lawmakers worrying about a potential spike in the number of people without coverage, or sharp increases in insurance premiums.

Adding to the pressure is the unified opposition of Democrats, many of whom view the 2010 healthcare law as the defining domestic achievement of Obama’s presidency.

House Democratic leader Nancy Pelosi said the U.S. Congressional Budget Office should be allowed to assess the impact of the healthcare bill before a vote is held.

In March, the CBO, a bipartisan research office, forecast that the first Republican-backed healthcare bill would cause 14 million Americans to lose their insurance by next year and 24 million more than now would be without coverage by 2026.

“Republicans have now made the bill even more costly and cruel to American families, likely resulting in millions more Americans not being able to afford coverage,” Pelosi said in a statement.

“The American people have a right to know the full consequences of ‘Trumpcare’ before their representatives vote on it,” Pelosi said.

Patient advocacy groups, including the American Heart Association and American Diabetes Association, also oppose the reworked bill, while the American Medical Association and others have expressed concerns over coverage losses and unaffordable insurance for those with pre-existing conditions.

If a plan passes the House, it is expected to face a tough fight in the Senate, where Republicans have a narrower majority and where some party senators have expressed misgivings about the House bill.

Senate Republican leader Mitch McConnell said on Tuesday that his party did not want to give up on the legislation.

(Reporting by Richard Cowan, David Morgan, Steve Holland and Doina Chiacu; Writing by Paul Simao; Editing by Dan Grebler)

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Exodus By Puerto Rican Medical Students Deepens Island’s Doctor Drain

CAGUAS, Puerto Rico — Myladis Reyes, 26, fell in love with medicine by accident. She was a sophomore at the University of Puerto Rico studying chemistry seven years ago when she visited her aunt, a clinic internist, in New Jersey and witnessed the difference she made with patients.

“She was always smiling. She always made little jokes,” Reyes said. “I just saw that and I thought, what better way to help?”

The experience showed Reyes a new way to harness her interest in science and directly improve people’s lives. But after a fierce struggle to get into medical school, she foresees challenges in finding hands-on medical training — known as a residency — in Puerto Rico. And because of poor job prospects on the island afterward, she expects her career to steer her far from home.

Studying medicine is a popular option among young Puerto Ricans. Acceptance rates at the commonwealth’s four medical schools are low and competition runs high. For example, Ponce Health Sciences University received 1,200 applications for its medicine program in the 2015-16 academic year. It accepted 180. Last spring, the Association of American Medical Colleges reported the island’s schools graduated a combined 277 medical students.

But many of those graduates are leaving the island for better work opportunities, despite Puerto Rico’s growing and urgent health needs.

In the Residency Match announced in March — where students learn where they will continue training — about half of students matched to the mainland, based on figures provided by officials at Puerto Rico’s four medical schools.

That exodus is particularly alarming because the commonwealth’s health care infrastructure is suffering from a shortage of trained physicians.

Physicians opt out of Puerto Rico for many reasons: Nearly 4 in 10 people in the commonwealth are insured through Medicaid managed-care programs, but payments for doctors and hospitals are a third less than the average payments by Medicaid managed-care organizations on the mainland. Most Medicare patients also use the private alternative — Medicare Advantage plans — but their reimbursements are well below mainland rates too.

The low payments are compounded by a $70 billion debt crisis in Puerto Rico. Last summer, Congress established an oversight board charged with saving the island’s economy. Its fiscal plan released in March calls for more cuts to provider reimbursements and fewer benefits for Medicaid enrollees, adding pressure to an economic recession that has helped drive thousands of physicians off the island.

To cauterize the bleeding, Gov. Ricardo Rosselló signed into law a measure that lowers physicians’ income taxes to 4 percent if they complete 180 hours of medically related community service or compensated care to Medicaid patients.

For medical students Reyes and Rafael Cardona, the uncertainty presents a large risk in deciding where to seek their medical residency and become licensed physicians.

As they near the end of their academic training and weigh their options, both are struggling to find a reason to stay.

A Tenacious Drive

Myladis Reyes, 26, has a clerkship at HIMA San Pablo Hospital in Caguas, Puerto Rico. While curricula in Puerto Rican medical schools resemble those of programs on the mainland, students like Reyes are taught in Spanish and English, making them enticing candidates for residencies overseas. (Carmen Heredia Rodriguez/KHN)

It took Reyes four rejections, two schools and a master’s degree to secure her place in med school.

As she finished her undergraduate program in biomedical sciences, Reyes submitted her application to each of the medical schools on the island. Her scores and GPA were lower than average, but she figured her personality during interviews could make up the difference.

She was turned down by each one.

Although the rejection was devastating, Reyes’ mother encouraged her to keep trying.

“She was like, ‘If you want it, you’ll find a way to get it,’” Reyes said.

She threw herself into a master’s program in health administration and finished with a 4.0 GPA. She raised her score on the standardized medical school application test by three points and volunteered at a Veterans Affairs hospital in the emergency room.

With more experience on her résumé and stronger scores, Reyes again applied to three medical schools, submitted more letters of recommendation and visited her preferred university multiple times to make sure they received her submission.

“I literally put [on the application], ‘If I don’t get in this time, don’t think that you won’t hear from me again next year,’” Reyes said.

Several months later, Reyes received a letter from her top choice school: Central Caribbean. She was in.

A Change In Direction

Rafael Cardona, 27, is a third-year medical student at Central Caribbean University, located in Bayamon, Puerto Rico. He wants to specialize in otolaryngology — focused on disorders of the ears, nose and throat — but the island has only one residency program for 10 people in that field. (Carmen Heredia Rodriguez/KHN)

Reyes’ classmate Cardona, 27, had nearly graduated with an electrical engineering degree before realizing he wanted to study medicine.

“I knew that if I wanted to do it, maybe I could,” Cardona said.

He began tailoring his electives toward biology and chemistry classes and picked up several more credits over the summer. The switch ultimately cost him an extra 12 months in college — taking him six years to earn his bachelor’s degree in 2014.

As both Reyes and Cardona fought for a place in medical school, scores of physicians were departing Puerto Rico. From 2009 to 2014, Puerto Rico’s total number of physicians decreased by nearly 2,400, according to the legislation that Rosselló signed in February. In 2014, 365 left. In the same year, only 278 residents completed their training. The following year, 500 doctors left the island, leaving behind only 293 new physicians to fill their void.

The exodus is partly fueled by financial incentives. Doctors working in the mainland earn two to three times more in wages than their colleagues in Puerto Rico. General and family practitioners here earned an average of $82,710 in May 2016. In contrast, the same doctors working in Oklahoma, the state with the lowest average earnings in the nation, earned $155,420.

Now in their third year of medical school, Reyes and Cardona are getting some hands-on experience through clerkships, where students spend several weeks at a hospital working with patients and physicians.

A stint in each specialty culminates in a shelf exam, where students are tested on what they learned in the field. This means the students’ lives revolve around practicing medicine by day and studying by night. Both Reyes and Cardona are up by 5:30 a.m. to be at the hospital by 7. They leave in the afternoon and head back to campus to study until about 11 p.m.

To Go Or Stay?

Reyes and Cardona have already begun to think about their future in medicine and how they will handle their residency applications for next year. They pay attention to the migration of Puerto Rican doctors and both intend to follow suit.

Cardona plans to leave Puerto Rico and go to New York. He wants to specialize in otolaryngology — a specialty focused on the ears, nose and throat — but Puerto Rico maintains only one program in the field. He is hoping to travel to the states next year to make some connections to residencies there. Ideally, Cardona said, he could return to Puerto Rico and re-establish roots.

“It would be really good if I could train in the United States, and if I could get a really good job in Puerto Rico,” he said.

Reyes said she intends to pursue a residency in the northeastern United States. The move means leaving behind her mother but a better salary to pay her student debt — totaling roughly $200,000 as of this year. With those bills, Reyes said, she cannot afford subpar pay.

“I have a debt to pay. And it’s pretty steep,” Reyes said. “I need to find someone that’s going to pay me” better than the residencies in Puerto Rico.

Categories: Cost and Quality, Health Industry, Medicaid, Medicare, Public Health

Tags: Medical Education, Puerto Rico

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Don’t let brittle bones shatter your life

Every year, more Americans are diagnosed with osteoporosis—a disease that causes bones to weaken and become more likely to break. You may not know that you have this “silent” disease until your bones are so weak that a sudden strain, bump, or fall causes your wrist to break or your hip to fracture. Learn the facts so you can protect your bones!

Many people believe:

  • Osteoporosis is a natural part of aging that only affects older women.
  • Bone loss can’t be treated once it starts.
  • The only risk of osteoporosis is broken bones from falls.

None of these myths are true. What is true is:

  • While 1 in 3 women over 50 will develop osteoporosis, 1 in 5 men will, too.
  • It’s possible to make bones stronger.
  • Around 25 % of people die within the first 6 to 12 months after a hip fracture.

Medicare can help you prevent or detect osteoporosis at an early stage, when treatment works best. Talk to your doctor about getting a bone mass measurement—if you’re at risk, Medicare covers this test once every 24 months (more often if medically necessary) when your doctor or other qualified provider orders it.

May is National Osteoporosis Awareness and Prevention Month. Learn more about what puts you at risk for osteoporosis and how to prevent and treat it at the National Osteoporosis Foundation. Watch our short video to learn more about how Medicare can help you protect your bones.

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Over 65? Age Out Loud!

Today’s older Americans are living longer and better lives. May is Older Americans Month, and it’s the perfect time to celebrate what getting older looks like today. When we come together to celebrate this year’s theme of “Age Out Loud,” we give aging a new voice—one that reflects what you have to say.

How can you get involved? Start by striving for health and wellness. The best way to stay healthy is to live a healthy lifestyle. You can be healthier and prevent disease by exercising, eating well, keeping a healthy weight, and not smoking. We’re here to help!

Medicare covers a yearly “Wellness” visit once each year. Schedule an appointment with your doctor or health care provider to make a plan to help prevent disease and disability. Be sure to print this checklist and take it with you, so you and your provider can talk about what preventive services can keep you healthy. Medicare pays for many of these services.

In addition to striving for wellness, there are lots of activities you can do to amplify your voice and raise awareness of vital aging issues across the country. Be sure to join your peers in trying new things, engaging in your community, focusing on your independence, and advocating for yourself and others.

Help promote Older Americans Month and this year’s theme of Age of Loud by using the hashtags #OAM17 and #AgeOutLoud on social media. Visit to learn more about how to celebrate your age.

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