Trump Scorecard-An Assessment of His First Three Years

Trump Scorecard-His First Three Years

No US president has inspired more vitriol than the current occupant, #45 Donald Trump. His supporters are quick to mention that he has done more than any other president, so this article reviews his policy changes and budget impacts in a handy table for your scrutiny.

Fact #1 Fiscal Spending & budget Fiscal prudence matters, the only president to reduce the national deficit in modern times was Clinton	Trump has blown up the federal deficit, which has increased 39% (Davidson, 2019) in 2019 alone, and directly reflects tax cuts he gave to the top 2% and big corporations. The national debt is now $1,000,000,000,000 (a trillion). The entire GDP of the US is 20 trillion (about 25% of global GDP). That’s a lot of debt to service and less money for other programs.	To understand what this means think of the world as a community pot of money where foreign investors, largely China buy US debt as an investment. Should they ever cease to do this, the nation would have a historically massive depression, ruining the livelihoods of your children and grandchildren.
Fact #2 Increased the risk for global terrorism by facilitating the release of Isis members held in Syria after pulling US troops out	Trump pulled US troops out of Syria, where our allies, the Kurdish army (where women are fighters) were slaughtered without warning and forced to side with Russian ally, Assad.	The complete and total betrayal of long-standing US ally, the Kurdish Army, has resulted in the growing power of Putin, who controls Assad.
Fact #3 Reduced the competitiveness and efficiency of US motor vehicles and accelerated the growth in greenhouse gases by rejecting Environmental Protection Agency scientific recommendations	Trump has rolled auto fuel efficiency standards back to 37 MPG versus 54 under the Obama Administration. He is also attempting to force all states to accept his reduced standards for fuel efficiency and greenhouse gas causing exhaust. For decades 17 states have chosen to comply with California standards, including Washington.	Like Reagan he longs for the 1950’s, but the rest of the world has moved on with higher performing vehicles and more efficient infrastructure for the future. Retarding innovation in the US will not help with jobs or economic security, let alone offsetting damaging global pollution-we’ll all be choking on US exhaust soon enough.
Fact #4 Ripping up long standing agreements with US allies, including NATO, the North Atlantic Treaty Organization	Trump’s current budget includes significant reductions in funding NATO, which is a bulwark against Russia aggression to our European allies.	The world is a small place and shredding agreements with our allies will not make the US stronger, but plays directly into Putin’s hands and could potentially help China.
Fact #5 Interfering with Military Tribunal Findings for War Criminals	Trump threw out the prison sentences for three Navy Seal members convicted of war crimes, overruling the highest command when removal of the Navy Seal Trident for these miscreants was imminent.	All branches of the military require a kind of blind service based on honor. Humiliating seven peers who testified against Gallagher does not enhance this valor or the safety of our troops.
Fact #6 Has used public money to finance religious based sham family planning clinics which do not provide basic birth control education or services	It is unconstitutional to use public funds to promote any religious perspective in education or healthcare or anything in the public domain.	Our founding fathers specifically created a secular constitution to avoid conflicts among sectarian groups. Freedom of religion doesn’t mean your ability to impose your will on others, but their freedom from religious tyranny.
Fact #7 Undermined the Affordable Care Act by making it more difficult for people to enroll and eliminated some funding sources	The ACA or Obamacare was a revenue neutral bipartisan act that created a marketplace for millions of Americans to get medical care by subsidizing the purchase of medical insurance. The ACA also removed the pre-existing conditions exclusion and other onerous insurance industry restrictions.	Making it more difficult for working class people to get healthcare undermines the economy and especially family survival. The US birth rate is at an all-time low because of family concerns over the high cost of healthcare, childcare, and education that have gone unanswered under Trump.

If the United States is to survive, we must find a way to stop the rhetoric about “sides” as anyone with a decent education knows there are lots of gray areas in life and the tricky part is accommodating them in policy making. To date I have yet to see anything tricky or masterful in the Trump Administration policy making. As the fervor of the religious right builds as they approach their eschatological climax, those of us who are more sentient are reluctant to embrace the greenhouse gas which envelopes our globe slowly simmering us all.

And this is the healthpolicymaven signing off encouraging you not to sign blanket medical releases before inpatient procedures and do specify that for which you agree and those treatments you decline. Do not allow someone’s else’s religion to determine your health care.

References

Davidson, K. (2019, June 12). US Deficit Grew 39% in First Eight Months of Fiscal Year. Wall Street Journal. Retrieved November 29, 2019, from https://www.wsj.com/articles/u-s-budget-deficit-grew-39-in-first-eight-months-of-fiscal-year-11560362539

Medicare-for-all Assessing Value And Cost At The Individual Level

This is the final article in this series comparing U.S. healthcare reforms and focuses on basic value at the consumer household level. Discussion will include how much people are paying for their health care and their health insurance in relation to actual value. Value is determined based on affordability and access to appropriate care for all residents. This article, like the others review healthcare from an individual consumer perspective not an insurance company or medical institution one.

Cost of Health Insurance

According to the 2019 Kaiser Employer Health Survey, the average cost sharing for a single employee is 18% of the cost of their group insurance, so using the $6,896 national cost per employee, this necessitates a $1,241 contribution. (Kaiser Family Foundation.org, 2019) Even though you have no family members you would still have to pay $100 per month just for the medical insurance plan. The cost sharing for employees with family members is MUCH steeper at 30% of family premiums for group medical insurance, which could be as much as $20,000 so their share is $6,000 on average. As a former insurance broker, I can tell you many employers don’t provide any premium payment assistance for family coverage, which means those workers could be on the hook for the full 20 K. This is $1,667 per month, which is the equivalent of a mortgage, except lots of people would not be able to afford a house payment after coughing up money for their medical insurance. In a generous spirit, the US government does allow employees to pay for these eye-popping costs with pre-tax dollars, which mean that wage earners with higher incomes are actually getting more of a subsidy for their medical insurance cost.

In 2018, 11.8 million people were enrolled in the insurance exchanges through the Accountability and Affordable Care Act (ACA-aka Obamacare). (CMS’ final report shows 11.8 million consumers enroll in 2018 Exchange coverage nationwide, 2018)These programs are for people who don’t have access to employer provided medical insurance or whose employer plans do not meet the minimum standards for cost and coverage under the ACA. The average out of pocket cost for an enrolled individual with family members was $1,415 after tax credits subsidies. The ACA was designed to provide affordable medical insurance for low-income and middle-class residents by paying them to obtain insurance, using federal tax credits. Essentially, this is deeply discounted insurance, because insurance companies which participate agree to accept the tax credit as a premium contribution. The main difference here is the cost sharing for family coverage is not as great under the ACA exchanges as under private sector insurance plans. However, there is a wide variety of prices in the insurance exchanges, based on the state, age of the enrollee, family status, and coverage selected. This figure was used to identify the most affordable ACA offering, which was the bronze plan. If a family wants the silver plan, the cost would increase by approximately 20%. Silver plans have lower cost sharing for services than bronze plans for participants.

Out of Pocket Costs Hitting US Consumers

Premiums or upfront contributions for the cost of medical insurance are only one aspect of healthcare costs born at the household level. Upfront expenses include co-payments for treatments, which can be quite steep, costing thousands of dollars for a single surgery.

Finally, the number one costly item for US healthcare consumers are prescription drugs, which many residents must pay completely out of pocket, while others have co-payments for generic drugs and name brand drugs. US consumers are currently spending $10,045 per capita for prescription medications, again an amount almost equal to a mortgage. According to AARP, the average retail cost for prescription medications for seniors was $30,519 in 2017.  And this picture gets bleaker, 500,000 people in the US spend over $50,000 a year on their medications, which is the average annual income of an employee! Adjusted for inflation, drug costs are nine times higher than they were in 1960.

Medicare for All Analysis

Medicare for all is on the lips of half the population today, but it is important to note that Medicare is in fact not a free healthcare program.  The Medicare program requires a substantial payment from the government to stay solvent, which is paid for by payroll taxes, of which 1.45% comes from employer’s payroll taxes and employees pay. This isn’t enough money to pay for all program expenses, so the federal government also allocates other funds as required. Medicare is the second largest expenditure for the US government at 14% of total budget. Personally, I don’t have a problem with the government spending the bulk of its funds on programs benefiting the people, but we do have an obligation to make sure these programs are reasonably sustainable. Only Social Security expenditures exceed Medicare consuming a whopping 38% of the federal budget. Medicare costs are increasing and the taxes to pay for them will also. It is difficult to see how it can remain solvent without a payroll tax increase in the near future.

Secondly, Medicare participants do contribute to the cost of their care, through monthly premiums and co-payments for services. For the fortunate enrollees who can afford good supplemental insurance plans, those co-payments are paid by private insurance companies. However, 19% of Medicare enrollees pay all of their co-payments out of pocket and another 33% of enrollees are enrolled on Medicare Advantage HMO type plans. Low income Medicare recipients are called dual eligible, meaning they are covered by Medicaid and Medicare and these represent 22% of all enrollees. That leaves only 26% of Medicare enrollees who have purchased private supplemental insurance.

This tables shows the healthcare cost factors for US households, both private sector and Medicare, and public and government spending.

Medicare for All Assessment Criteria

US healthcare expenses per person	Private insurance/non-Medicare sector	Cost for Medicare enrollees	Net Impact on non-Medicare household
Insurance premiums	6,896	2,018
Co-payments for services	2,200	5,806
Household totals	9,096	7,824	-1,272
Government cost	6,748	10,986	4,238
Estimated additional gov cost for non-Medicare enrollees			2,966 per capita

Notes

All figures are annual calculations, as true to per capita as possible.

The US government spend for private sector healthcare includes tax subsidies and comes from the GOA.

Medicare premiums are for Parts B and D as Part A is offered at no charge. Medicare supplements are not included because the price range was too great and only about half of Medicare enrollees have them. Instead the cost sharing figure for all Medicare enrollees was used.

The co-payment number is based on the private sector mean.

In conclusion it is important that we all have realistic data and expectations regarding the adoption of any national healthcare program. Based on my calculations, a 3% payroll tax, which would be born by employees and their employers would be enough to pay for the program. The US could for example adopt a national healthcare model like Australia where only hospital coverage and basic care is provided. Access to specialty care in Australia is subject to supplemental payments. However, there are many different ways to pay for national healthcare programs and examples include a VAT tax like Canada uses or a combination of income taxes and fees, like France uses. France has a tax on pharmaceutical companies to help pay for its national healthcare program, which could work in the US.

It is also vital to consider unintended consequences of pouring a lot more government money into a health system that is rife with abuses. A national healthcare program would have to curb abuses such as overcharging, eliminating incentives for unnecessary procedures, and focusing on primary health, not just geared toward making money. Reimbursements for services must be adequate, but it is to be expected that certain sectors, like insurance, pharmaceutical, medical suppliers, and some providers would be earning less.  Of concern is the fact Congress seems unable to control its spending, so this could really blow things up fiscally.  I suggest we appoint citizen representatives with knowledge of the healthcare industry for 4-year terms, with blinded voting, to avoid excessive pressures from the lobbying terrorists. Oh, and let’s overturn Citizens United and get back to the original voice of democracy in the USA.

And this is the healthpolicymaven signing off encouraging you NOT to sign blank medical release forms when you agree to procedures, to specify that for which you consent and that for which you decline.

This article was written by independent healthcare analyst and journalist, Roberta E. Winter and is not subject to any corporate approval. She is the author of a guidebook to the US healthcare system which focused on assessing quality. (Winter, 2013)

Works Cited

CMS’ final report shows 11.8 million consumers enroll in 2018 Exchange coverage nationwide. (2018, April 3). Retrieved October 27, 2019, from Centers for Medicare and Medicaid: https://www.cms.gov/newsroom/press-releases/cms-final-report-shows-118-million-consumers-enroll-2018-exchange-coverage-nationwide

Kaiser Family Foundation.org. (2019, September 25). Employer Health Benefits Survey. Retrieved October 27, 2019, from Kaiser Family Foundation State Health Facts: https://www.kff.org/report-section/ehbs-2019-summary-of-findings/

Winter, R. E. (2013, July). Unraveling US Healthcare-A Personal Guide. In R. E. Winter, Unraveling US Healthcare-A Personal Guide (p. 216). Rowman & Littlefield. Retrieved October 27, 2019, from https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

How the US Healthcare System Compares to Other Large Democracies

Comparison of Large Democracy Health Systems

Continuing the informed conversation on health systems from the previous post[1], this table shows how the US compares to several large democracies with national healthcare systems which include private insurance and clinics.

Criteria	France	Germany	Australia	USA
National mandate for healthcare access and insurance protection	Insurance is provided to up to 99% of residents; hospitals are owned by the government; clinics can be public or private; health insurance is required, through three government run companies; workers pay up to 8% of income and employers pay 13% as a wage tax	Insurance is mandated for all and residents pay up to 8% of gross income into the nonprofit state-run insurance program;employers and employees contribute to a comprehensive health, long term care, and accident protection program; insurance may be either public or private; group healthcare was standardized here in 1883	Has a national healthcare system called Social Security, which provides hospital coverage, but not  all of outpatient care; financed by 1.5% tax on gross income (2.5% if you lack private supplemental insurance)	Hodge podge system, VA and private insurance varies widely by region; medical insurance was mandated under the PPACA but was reversed by Trump; Medicare is paid by a 1.45% payroll tax on workers and employers; lack of hospital price transparency
Public versus private care hospital overview	62% are Public 24% are private nonprofit and 12% are for-profit hospitals	50% are Public hospitals and the rest are a mix of nonprofit and for profit	66% are public hospitals, 33% private; public hospital care is free to residents	20.% government owned hospitals, 58.5% are nonprofit and 21.3% are for profit
Specialty care is readily available	Yes, doctors even make house calls	Yes	Yes, in western Australia, less so elsewhere	Yes, if you have the money to pay
Hospital bill per discharge	$11,149	$6,122	$10,874	$21,186
Private insurance is available	Yes	Yes	Yes	Yes, and is a must if you want care
Cost of healthcare per capita	$4,600	$5,551	$4,708	$9,892
Cost of care born by government	86%	85%	69%	51%
Average cost of health care paid by residents per month	10€ or $11, very small co-payments; referrals may be required for specialists in order to get max benefits	Germany limits cost-sharing to a 2% max of income, which is a little over $100 per month; All Germans contribute to the healthplan, roughly 400€ or $500	$167/person is the average cost for private insurance/person; co-payments are limited to $25	CMS estimates Americans spend $267 in out of pocket expenses and over $500 for insurance premiums
Per capita spend for insurance administration	$272	$255	$123	$787

Conclusions

The American people pay a much higher percentage of total health system costs than residents in the other democracies. And residents of the US are not getting better quality care for that huge disparity. Considering the average cost for unreimbursed care and the typical insurance contribution born by an American worker, totals $9,200 per year, this money could be invested for a healthy retirement savings or to purchase a home. Voters of millennial-age are realizing this rip-off, which is why they support transformation in the government through Bernie Sanders and Elizabeth Warren. It has taken a few decades but the majority of Americans are finally realizing the current system of healthcare in the US is failing them.

And this is the healthpolicymaven signing off, encouraging you NOT to sign blanket releases when you have inpatient procedures done, do indicate that for which you consent and that for which you decline. If you are intimidated by medical jargon and administration procedures, bring an advocate.

References

Institute for Quality and Efficiency in Health Care. (2018). Health Care in Germany; The German Health Care System. NCBI, NLM,National Institutes of Health.gov. Informed Healthcare.org. Retrieved September 30, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK298834/

Petersen-Kaiser Health System Tracker. (2019, September 30). Petersen-Kaiser Health System Tracker. Retrieved from Henry J. Kaiser Foundation.org: https://www.healthsystemtracker.org/indicator/access-affordability/percent-insured/

The Commonwealth Fund.org. (2019, September 30). International Health Care System Profiles. Retrieved from The Commonwealth Fund.org: https://international.commonwealthfund.org/countries/

Tikkanen, R. (2019, September 30). Multinational Comparison of Health Systems Data, 2017. Retrieved from Commonwealth Fund.org: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_chartbook_2017_multinational_comparisons_of_health_systems_data_2017_rtikkanen_pdf.pdf

Transferwise.com. (2019, September 30). Healthcare in France: A Guide to the French Healthcare System. Retrieved from Transferwise.com: https://transferwise.com/us/blog/healthcare-system-in-france

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[1] https://healthpolicymaven.blogspot.com/2019/09/debunking-myths-about-national.html

Debunking the Myths About National Healthcare

An analysis of the Myths of National Healthcare Constipating Real Reforms

Myth #1 A government run healthcare program eliminates your private insurance

 No, this is incorrect and a good example of a government run healthcare program is Medicare, which has been around for over 50 years. Medicare is made up of several parts; Part A which is for inpatient coverage, Part B, which requires a monthly premium provides outpatient coverage, Part C, which is the Medicare Advantage Plan-a somewhat integrated health plan, and Part D, the prescription drug coverage added by President George W Bush. This was back in the day when Republicans wanted to provide benefits for people rather than take them away. Private insurance companies’ partner with Medicare to lower cost-sharing for seniors, improve drug coverage, and increase access to specialty care, and these are known as Medicare supplements. Though this may seem a convoluted way to get the various components of healthcare met, it does work. Medicare also is very effective for several reasons.

1.  All seniors, persons age 65 and up are covered on Medicare, which is also a group that private insurance companies are glad to have the government insure. This is a demographic group that is highly likely to need healthcare services and whose access to healthcare would not be possible without government healthcare.

Myth #2 A government run health plan will cost too much

This assertion is also incorrect as every country with a national government run health system spends far less than the United States and boast better results in many clinical areas. For example, according to the Petersen/Kaiser Health System Tracker in 2016 the US spent $10,238 on average per person for healthcare. (Petersen/Kaiser Health System Tracker, 2019) But as we know, many people went without healthcare at all, so this figure, although higher than other industrialized countries by 50% represents the skewing of healthcare services to a much small percentage of the national population. France spent $4,600 per person and everyone has had access to an integrated health system for decades. Japan spent $4,519. The average spent by industrialized countries was $5,198, less than half of what the US spends. Further, an integrated national health system will be less expensive to administer and a good example of that is Medicare and here are some reasons why:

1.  Medicare administration expenses are 6% of total plan expenses as opposed to 12-18% for private sector plans, which means it is less expensive. 
2. Medicare requires Medicare Advantage plans, which are supplemental insurance, to spend at least 80 to 85% of the premiums collected on actual medical claims, which mutes excess profiteering. And CMS requires them to issue customer rebates if they do not meet those loss ratios for benefits paid out. This is similar to the standards private sector insurance must adhere to in Europe. 
3. Medicare already determines what services are approved for reimbursement, which all private sector insurance plans adopt, so it would be efficacious for it to set national standards.

Myth #3 You won’t be able to see your private doctor

This assumption is also incorrect as other countries with government run health systems do have private clinics and private doctors which their citizens enjoy. In fact, the United Kingdom Health System which is a totally government run health system is not the norm. Other countries with national health systems, like France the Netherlands, or Australia use a combination of public and private programs to provide healthcare. The difference is, a much smaller segment is provided by private insurance companies. Of course, the behemoth insurance industry in the US is not going to be in favor of a smaller market share. However, this does NOT mean this position is better for you, the consumer or the patient and I state this as a former insurance broker.

Myth #4 Most Americans have Access to Health Insurance Through Employer Provided Plans

Again, this assertion is false as only half of US employers provide medical plans to their workers. (Kaiser Health Facts, 2019) And of that number, employers are increasingly forcing more of the costs of medical care onto their employees through higher premiums, higher co-payments, and reductions in benefits. Ergo, people already realize they are paying for the cost of their healthcare, and paying more than anyone else in any other nation, but we need to move toward the discussion of value. The question needs to be, is that $1,000 monthly insurance premium and that $5,000 co-payment for surgery less expensive than a national healthcare plan and that answer is profoundly no. No one in any country with a national health system is expected to pay a $5,000 co-payment for medically necessary surgery. In fact, the joint replacement surgery to which I refer could be done for that co-payment price in many European countries. Americans need to start discussing value-what are you getting for that extremely high cost of care.

Further, the Republicans promote the idea that worthwhile residents have health insurance and the others must be lacking in some social value and this is not in keeping with current employment practices. The gig economy includes highly specialized and educated workers from throughout the globe and they work without benefits. It is not only farm workers who lack healthcare, but a huge swath of the workforce. An excellent reference for the impacts of this work force change is Mary Gray and Siddharth Suri’s Ghost Work-How to Stop Silicon Valley from Building a New Global Underclass. (Suri, 2019)

 A Better Approach

A better approach to improving US healthcare needs to consider who is paying for services, not just how much they are paying, because more and more the middle-class workers are being gouged for the cost of their healthcare. This needs to stop and the solution is to reform the US health system into a saner, less expensive, inclusive one, that is used by all other industrialized countries in the world (national healthcare). Some things to consider in streamlining the US healthcare system include things that Medicare is already doing with a national impact:

1.  The Centers for Medicare and Medicaid (CMS) are part of Health and Human Services Agency and are the main fraud detection arm to prevent criminal activity in the healthcare system. It is in the best interest of all patients and tax payers to have an independent government agency monitor and enforce anti-fraud efforts and prevent the use of unapproved medical devices and products in the healthcare system.
2.  Medicare is best suited to bargain with private sector entities for pricing of products and with the largest customer base, also in the best position to get lower prices than anywhere else. Private sector companies exist to make money, which means you pay more. If CMS through Health and Human Services has the power to bargain with pharmaceutical companies, you will see an immediate drop in the cost of your prescription medications. Why should Americans continue to pay more for medications that are sold to patients in Europe, with socialized health systems for significantly less?
3.  Medicare already uses medical evidence to inform changes in approved treatments and these are piloted through demonstration projects. Medicare with its huge patient population can provide excellent data for future health system improvements. An example of this was the move to spend Medicare money to keep seniors in their homes because it was proven to reduce hospitalization costs and improve patient health.

 A national health system for all will eliminate some of the conflicts of health system profit making procedures versus lower cost more efficacious health treatments that are less lucrative. The current health system relies on up-selling of medical imaging, laboratory, and elective surgeries to generate margins and produce financial results. Healthcare should be focused on helping people live quality lives, not producing profits. And the health of a nation needs to be devoted to population health measures, methods, and outcomes, not designed to benefit a few winners of the healthcare lottery.

And this is the healthpolicymaven signing off encouraging you not to sign blanket releases for medical procedures which require hospitalization, do specify that for which you agree and that which you decline. And try to bring a healthcare advocate with if you are mystified by medical terminology.

Roberta Winter is an independent health policy analyst, patient advocate, and author of https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

Kaiser Health Facts. (2019, September 1). 2018 Employer Health Benefits Survey. Retrieved from Kaiser Family Foundation.org: https://www.kff.org/report-section/2018-employer-health-benefits-survey-summary-of-findings/

Petersen/Kaiser Health System Tracker. (2019, September 1). How Do Healthcare Price and Use in the US Compare to Other Countries. Retrieved from Health System Tracker.corg: https://www.healthsystemtracker.org/chart-collection/how-do-healthcare-prices-and-use-in-the-u-s-compare-to-other-countries/

Suri, M. L. (2019, September 1). Review of Ghosst Work. Retrieved from New York Journal of Books: https://www.nyjournalofbooks.com/book-review/ghost-work

Russell Ride 2019-Post and Video Clip

Excerpt from the 2019 Russell Ride Journal followed by a Utube clip

Day 1-Following a grinding work day on Friday the 21^st, I opted to leave at 7:30 AM instead of 6:00. This decision proved stressful as weekend traffic was thick, post summer solstice and hitting the peak of tourist season in the Pacific Northwest. Luckily, I knew the route, slamming along Route 3 past the navy ships mothballed on shore until I exited onto “old Belfair Highway” and a bike lane. Then an easy mostly flat 10-mile ride into Belfair and a climb along the tree-lined highway towards Shelton. Past Herron Island and the northern Puget Sound outposts of Allyn and Grapeview, the route to the logging town of Shelton is preceded by a paved shoulder which is 24 inches wide at most. This seemingly adequate safety zone fails to consider the intrusion of mirrors which extend 18 inches from the passenger side of the commercial trucks, pickups, and recreational vehicles. Consequently, the cyclist must ignore the danger and ride a steady line.  

Aside from the late start I was soon pelted by rain all of the way into Mason County’s largest town. Nathan spotted me and did a quick pull over so we could take a photo to document the conditions, wet and miserable. Shelton is a 2-hour ride from Bremerton and entering the timber hub requires meandering around warehouses and various highway intersections. I am always relieved when I see the “Welcome to Shelton” sign as I leave town. There may be amenities here but they are opaque to the visitor, even someone going 15-miles-an-hour. I do not even recall a park with a restroom.

After a short highway jaunt on 108, I turn off at the McCleary casino which is my half-way rest stop. No flush toilets here, but a nice selection of porta pots and a picnic table with some historical markers. Nathan meets me here, right on schedule and we chat for 20 minutes. From here, I am now riding on smooth pavement along country roads, past farms and scaling a surprising number of hills. Once in the village of McCleary I turn left onto a beautiful bike path all the way into Elma, a sweet little town with some urban planning forethought including actual bike lanes. The land becomes flatter here, but the headwind increased to 20 MPH. I wryly observed my speed decrease on my odometer despite my best efforts. At one point I pulled into a bus shelter for a respite. Luckily, the rain had abated and it was sunny. I soldiered on to Montesano and the smiling face of my son, in the IGA parking lot. 

Nathan rode from Montesano, with a westerly crosswind and I waited for him 30 miles away in Raymond, a timber town. Weyerhaeuser owns most of the land in the region, but the town is on a river and is quite scenic with verdant hills all around. It even has sculptures along the road, a sure sign of affluence. I don’t remember much about it from last year, probably because I was so intent on getting into Astoria. South Bend is a charming town just west of Raymond with a bike path along the water and a great bike tool station with restrooms! I waited for Nathan here. He seems to be a strong rider and looks awesome in his made-in-the-US Borah gear! The goal is to camp tonight, so I need to find a site before dark and then circle back and find him. Destination-Cape Disappointment State Park on the Long Beach Peninsula.

Having plenty of time to kill, I decided to try and visit the man whom had helped me last year on the inaugural Russell Ride. I drove to his humble home and the place looked fairly deserted. I also saw a “for sale sign” off the road. I sure hope he didn’t die from his diabetes induced dialysis. Anyway, I left him the articles about the research the Russell Ride contributed to in 2018 and about this year’s ride. I also left him a brochure from Benaroya Research Institute.

https://www.youtube.com/watch?v=Vsy5eEhr5a0&feature=youtu.be

https://benaroyaresearchinstitute.everydayhero.com/us/russell-ride-2019

US Does Not Guarantee Healthcare To Diabetics Until Kidney Failure

If you are a diabetic in the United States, you will pay more for your insulin than anywhere else in the world and you are much less likely to have insurance pay for your required care. Presently, if a diabetic lacks private insurance, the U.S. government does not guarantee any medical care for that person until he or she is in end-stage renal failure, which means on kidney dialysis.  This provision is thanks to a 1963 act of Congress authorizing Medicare inclusion for those in end-stage kidney failure. If an individual is on Medicaid, which is for low-income folks, healthcare is provided. But working-class people without insurance are left out in the cold, unable to afford private insurance and struggling to buy their insulin.

The Trump Administration is suing the federal agency charged with administering the Patient Protection and Affordable Care Act known as Obamacare, which is one of the few methods that people can obtain affordable health insurance. In the United States only 52% of employers provide any kind of medical insurance or workplace benefits. Consequently 48% of the working population lacks access to affordable healthcare. In addition, if the Trump Administration gets its way it will rollback protections for people with pre-existing conditions and they will be unable, in many cases, to obtain any medical insurance. Keeping with current trends the Trump Administration and Senate leader, McConnell are intent to take the nation back to the fifties, not 1950, but 1850.

The US does not guarantee any access to primary healthcare for people with chronic diseases, like Type 1 Diabetes and in fact, many cannot afford to pay for their insulin, and some have died. This needs to stop.

1.  Firstly, as a nation we need to start providing primary care to prevent kidney failure for diabetics and others. Providing care earlier will reduce problems and costs later. 
2. Secondly, we need to reduce the manipulations of the pharmaceutical industry to continually up-sell scant changes in patent formulations which restrict access to affordable generic drugs.
3. Thirdly, the Food and Drug Administration should represent the people of the United States and quit viewing pharmaceutical companies as its customers. A regulatory agency must maintain a separate authority from those it is policing. 
4. Fourthly, let’s restore the application of quality science in health policy decision-making. 
5. Finally, establishing a national healthcare policy, like Medicare-for-all would alleviate a number of these challenges, by providing a baseline of care, establishing one government authority to negotiate for pricing for health products and services, and lowering administrative costs.

 To that end, I am once-again riding the Russell Ride from Bremerton, Washington to Napa, California to promote the research Benaroya Research Institute is doing to cure Type 1 Diabetes, an auto-immune disease which took my brother at age 42. I will be speaking with people along the coast and listening to their stories about their diabetic challenges. This year, my son, Nathan will be riding with me. Join us for the Russell Ride by following me on Twitter or on the fundraising site below.

https://benaroyaresearchinstitute.everydayhero.com/us/russell-ride-2019

https://twitter.com/healthpolicymav

And this is the healthpolicymaven signing off encouraging you not to sign blanket medical releases, but specify that for which you consent and what you decline. And do consider making a contribution to the site, I hope to obtain 100 contributions this year.

Women's Health-The Attack on Reproductive Health

Women’s Health Revisited-Reproductive Health and Violence Towards Women

State healthcare laws impact women and should be considered by anyone thinking of relocating within the USA. Primary measures of women’s health and well-being include: access to reproductive services, availability of birth control options, maternal death rates, proportion of women covered by medical insurance, and violence against women. In order to keep this a blog-sized article, this analysis reviews; reproductive services, sex education mandates, and reported rates of rape, murder, and aggravated assault, which includes domestic violence. A subsequent issue will explore other components of women’s health.

Access to Abortion

Roe-v-Wade, the Supreme Court ruling which made abortions legal in the United States was enacted in 1973. The majority of the national population felt that abortion should be legally available to women then and still do today.  A 1979 study conducted by the Gallup Organization found 80% of the population believed abortion should be legal and 70% thought it should be available to women on Medicaid. (Public Perception on Abortion) It should be noted, the survey was commissioned by Redbook Magazine, which would have targeted a largely female population, so this acceptance of abortion rights may reflect the feminine viewpoint. A Harris Group poll at the time found 60% of Americans thought abortion should be legal in all cases. Fast forward to 2018 and Pew Research found that 58% of Americans still think abortion should be legal and only 15% were willing to say that abortion should be illegal in all cases, including rape, incest, and when the woman’s life is endangered. (Public Opinion on Abortion, 2019) The latter must view women as a host body rather than as emancipated individuals.

Table of Abortion Laws

Most Restrictive	Moderately Restrictive	Least Restrictive
Bans at 0-12 weeks gestation, which is during the first trimester of pregnancy	Allows abortion during the second trimester of pregnancy; 12-24 weeks gestation	States which permit abortion to-24-weeks and into the third trimester; depending on the circumstances
6 weeks-Louisiana* Senate Bill 184 proposes banning abortion at fetal heartbeat detection, which is during the embryonic stage (Clark, 2019)	Louisiana current law permits abortion to 15 weeks, which is 2 weeks past the 1st trimester	States permitting abortion to 24 weeks; CA, CT, DE, HI, ID, IL, MD, ME, MI, MN, MO, MT, NY, TN, WY
6 weeks fetal heartbeat law was voted unconstitutional by the North Dakota Supreme Court in 2016. ND has since voted to outlaw dilation and evacuation procedures, criminalizing doctors who perform them (Lam, 2019)	North Dakota current law permits abortion to 22 weeks	Massachusetts law allows abortion up to 27 weeks past the last period
18 weeks-Arkansas abortion ban was signed by Governor Hutchinson in March 2019. (Arkansas Governor Signs 18 Week Abortion Ban Into Law, 2019)	Arkansas current law allows abortion within the 2nd trimester	Virginia permits abortion at 25 weeks
6 weeks-Mississippi Governor Bryant signed a bill in March 2019 banning abortion at fetal heartbeat or 6 weeks past-last-period (Blinder, 2019)	Mississippi- current law permits abortion to 20 weeks, but restriction to 15 weeks is under litigation	These states permit abortion for lethal fetal anomaly: MS, GA, LA, SC, TX, DE, MD
6 weeks-Florida has a bill pending to restrict abortion once there is a fetal heartbeat, which is during the embryonic stage, so 6 weeks or less of pregnancy; and to make doctors performing abortions felons (Weiss, 2019)	Current Florida law permits abortion to 24 weeks	These states permit abortion to viability w/o restriction, leaving the decision to the clinician and patient: AK, CO,DC, NH, NJ, NM, OR, VT Bans partial birth abortion; NH
House Bill 28 would outlaw abortion after 13 weeks in North Carolina (Cross, 2019)	North Carolina- current law allows abortion to 20 weeks	Michigan permits post viability abortion if a woman’s health is endangered
Senate Bill 1867 was signed by Arizona Governor Ducey, would require doctors to give life-saving treatment to aborted fetuses (Rau, 2019)	Arizona-has passed a law mandating a rollback to 20 weeks which is under litigation	Arizona currently allows abortion to 25 weeks
Ohio’s fetal heartbeat bill passed the legislature but was vetoed by Governor Kasich	Ohio current law allows abortion to 22 weeks	Permits abortion to viability for rape and incest: MI
Similar efforts to restrict abortion to 6 weeks also include:  Kentucky, South Carolina,Tennessee, and Texas. A Texas bill failed in April 2019 and would have included the death penalty for women who have abortions for any reason and for clinicians who perform them.	AL, AR, GA, ID, IND, IO, KS, KT, LA, NB, OK, SC, SD, TX, WV, WI all permit abortion up to 22 weeks	States permitting abortion to viability  if woman's life is endangered: RI, MI States permitting abortion to viability for fetal abnormality: MD, DE
Utah has an 18 week ban on abortion in their 2019 legislative agenda	FL, MA, RI, NV, and PA permit abortion to 24 weeks	Utah permits abortion to viability for-rape, incest, and lethal fetal anomaly

Notes-

*All first trimester bans are under review by the courts and are not currently allowed. The now conservative US Supreme Court is expected to hear some of these cases this year. Several states are trying to limit abortion from the point of fertilization or at the embryonic stage, which occurs within two weeks of the sperm penetrating the egg during intercourse, and before a woman would know she is pregnant. These folks must have skipped biology class as a fertilized egg is not a baby.

Availability of Contraceptive Services

Catholic hospitals have repeatedly been found not to comply with state laws regarding the availability of emergency contraception for women whom have been sexually assaulted. A California study found only 66% compliance among Catholic hospitals. (National Women's Law Center, 2019)

Table of Laws Governing Access to Birth Control Options

Criteria	Most Restrictive for Sexual Activity	Least Restrictive for Sexual Activity
Access to Abortion Clinics (Citizen Access.org, 2019)	States with the fewest number of abortion clinics for the eligible population of females, each with only 1 clinic: MS, MO, KT, ND, SD, WV Other states with a dearth of facilities: AL, SC, LA, WI, UT, TX These states may have adequate abortion facilities, based on population but they are not geographically dispersed: MN, IA, ID, WY, NE, KS, OK, AR, TN, DE, RI, HI	States considered to have acceptable access to abortion clinics: CA, OR, WA, CO, MT, GA, AK, NC, VI, MD, NJ, PA, NY, NH, VT, ME, CT
Availability of Morning After Pill This is commonly known as Plan B was approved by the FDA in 2011 (Princeton University, 2019) Because this is emergency contraception it must be administered within 120 hours of sperm exposure.	States which do not mandate information on emergency contraception even in the event of rape: MS, MO, GA, NC, LA, ND, SD (NCSL.org, 2019)	States permitting pharmacists to prescribe emergency contraception to women of any age: AK, WA, CA, HI, NH, NM, VT, ME, MA States with reporting mechanisms for hospitals that do not comply with emergency contraception notification for rape victims: HI, MN, NJ, NM, IL OR, UT, WA, and WI (Washington Women's Law Center, 2019)
Birth control RX is mandated coverage for private insurance; although self-insured plans under ERISA are exempt as are religious entities (Laurie Sobel, 2019)	No mandate to cover RX contraceptives on government plans in: TX, TN, VI, OH	All other states mandate RX contraceptive coverage on private insurance plans
Birth control RX is mandated coverage for state agencies Abortion covered by insurance (Guttmacher Institute, 2019)	No mandate to cover RX contraceptives on government plans in: TX, TN, VI, OH States with limited insurance mandates to cover abortion: AZ, ID, IN, KS, KY, MI, MO, NE, ND, OK, UT	These states will not allow any exemptions for state or private agencies: CO, GA, IA, MT, NH, NV, VT, WA, WI (Laurie Sobel, 2019) Medically necessary abortions must be covered by insurance: WA, OR, NJ, NM, NY, IL, HI, CT, CA, AZ, AK
Mandated sex education in public schools (Guttmacher Institute.org, 2019)	These states have no mandate for sex education in public schools: AZ, CO, FL ID, MA, VI, TX, LA,	States requiring sex education to be medically accurate and also provide education on sexually transmitted diseases: CA, DE, DOC, GA, HI, IA, KT, MN, MD, MS, MT, NV, NJ, NM, NC, ND, RI, SC, TN, UT, VT, WI
Nonprescription birth control measures (condoms) widely available at retail outlets	Some states like TX, AR, and DE have laws requiring condoms to be distributed by MD’s or Pharmacists-These laws are typically not enforced. (McDevitt, 2016)	Metropolitan areas throughout the US have condoms in grocery, drug, and convenience stores. Individuals can have condoms delivered to their home from Amazon or the Condom Super Store.com
Adequate supply of OBGYN and primary care providers (Citizen Access.org, 2019)	Inadequate supply of primary care for women in: ND, SD, MO, IO, IND, WI, KT, WV, UT, MS, TX, GA, LA	Adequate supply of primary care for women: WA, OR, CA, NY, MA, MI, IL, PA, NJ, NC, VI, MD, FL

Assault and Violence-A Statewide Analysis

Using the Federal Bureau of Investigation Crime Statistics for 2017 I analyzed rape, murder, and aggravated assault, which includes domestic violence statewide. The tables below show the safest and most dangerous states for women to live. Scores compare the variance between the national average and each state’s metrics including the Washington DC area. A negative score means these states had fewer incidents than the national average and conversely a positive score means the state had greater incidents of violence. These data are combined male and female rates, but 79% of all violent crimes were committed by men and women were victims 48% of the time. However, 93% of rapists were male and 89% of their victims were female. Likewise, for murder,78% were men and 24% of the victims were women.  (Federal Bureau of Investigation, 2019)

Safest Places

The safest places to live in the USA are the northeastern states of Maine or Vermont or the eastern seaboard states of Connecticut or Virginia. These states all tend to have good education systems and fairly high taxation. If you are a woman living in Maine you are 3 times less likely to be raped, nearly 5 times less likely to be murdered and 3 times less likely to be assaulted than for a woman in Alaska.

Table of Safest Places in the United States

Health Metrics	For Violence	Statewide
Measures based on 2017 FBI data	National Incidence Rate per 100,000 people	Maine	Connecticut	Vermont	Virginia
Rape	41.7	35.4	23.3	35	33.8
Score		-6.3	-18	-6.7	-7.9
Murder	5.3	17.	2.8	2.2	5.3
Score		-3.6	-2.5	-3.1	0
Aggravated Assault	284.9	65.3	123	114	118
Score		-220	-162	-171	-167
Combined Score		-230	-182	-181	-175

 Most Violent Places

In terms of this ranking methodology, the goal is to have fewer events than the national average for acts of violence but as you can see, these states have high rates of aggravated assault, rape, and murder, compared to the national incidence rate. It is difficult to draw conclusions from this grouping as they are so varied. Most worrisome is the rape statistic for Alaska, which I triple checked and represents 32 out of 39 agencies reporting their data for 2017.  Alaskans have 386 more incidents of these violent crimes per 100,000 people than the national average, due largely to the rape metric.  However, the assault rate was high in Alaska as well.  The highest murder rate in the nation was in Washington DC, with more than twice as many murders than the national average for 2017. The rate of assaults in DC is similar to Alaska. About the only things that Alaska and New Mexico have in common are large tribal populations, which may explain some of the violence. But Montana also has significant tribal populations and their violence metric was much lower as was North Dakota's, where the Pine Ridge Reservation is located.

 Table of Most Violent Places In the United States

Health Metrics	For Violence	Statewide
Measures based on 2017 FBI data	National Incidence Rate per 100,000 people	Alaska	Washington, District of Columbia	New Mexico	Tennessee
Rape	41.7	116.7	64	60.3	43.7
Score		75	22.3	18.6	2
Murder	5.3	8.4	16.7	7.1	7.8
Score		3.1	11.4	1.8	2.5
Aggravated Assault	284.9	575.4	546.3	537.8	483
Score		290.5	261.4	252.9	198.1
Combined Score		386.6	295.1	273.3	202.6

 Conclusion

In my 15 hours of research for this article, I decided the issue of female autonomy and reproductive rights is too complicated for one article. This analysis has attempted to show the level of vitriol lobbed against women’s constitutional rights at this moment, during the Trump Administration. Though the anti-abortionists have been relentless in their assaults on state laws governing women’s health and the clinicians whom provide these services, they have only managed to change public perception by 2%. According to a recent Pew Research poll only 2% fewer Americans believe abortion should be outlawed.  All of the harassment, personal injury, and even deaths caused by the irrational cabal of personhood-fetus-promoters has barely managed to move the dial. One can only hope that doctor patient privilege and privacy will be protected by the courts. But with the statewide and more recent federal court appointments hueing conservative, we can anticipate an increase in the rate of incarceration for women whom are merely trying to make informed decisions for their lives. At the Supreme Court we can count on newly minted Justice Kavanaugh, who doesn’t hate all women, just the ones who disagree with him, to vote against women’s autonomy at every turn. (Congressional Record, 2018) (AP, CNN, 2018)  

And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when entering an inpatient facility. Do stipulate that for which you agree and for which you decline.

This article was written by Roberta E. Winter, MHA, MPA a freelance journalist and is not subject to approval of any corporate or government agency. Winter is the author of Unraveling US Healthcare-A Personal Guide, published by Rowman and Littlefield in 2013. Research for this article will inform an update to her healthcare guide. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

80% of Americans Believe Abortion Should Be Legal-70% Approve Medicaid Funding. (n.d.). Retrieved April 6, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/383496

AP, CNN. (2018, September 28). Key Moments from the Ford and Kavanaugh Hearings Video. Retrieved from The Guardian: https://www.theguardian.com/global/video/2018/sep/28/key-moments-from-the-ford-and-kavanaugh-hearings-video

APnews.com. (2019, April 6). Retrieved from Associated Press News: https://www.apnews.com/e41973cb7e7c4441b77d90e852568401

Arkansas Governor Signs 18 Week Abortion Ban Into Law. (2019, March 15). Associated Press. Retrieved April 11, 2019, from https://www.apnews.com/b0e1e6fb69c6414e89ecadb0f4dd8178

Blinder, T. W. (2019, March 21). The New York Times. Retrieved April 11, 2019, from https://www.nytimes.com/2019/03/21/us/abortion-laws-states.html

Citizen Access.org. (2019, April 7). Data shows unequal access to abortion clinics nationwide. Retrieved from CU-Citizen access.org: https://www.cu-citizenaccess.org/2019/02/08/data-shows-unequal-access-to-abortion-clinics-nationwide/

Clark, M. (2019, April 8). Law Banning Abortion After A Fetal Heartbeat is Detected Is Set for Consideration by Louisiana Legislature. Times Picayune. Retrieved April 11, 2019, from https://www.nola.com/news/2019/04/law-banning-abortion-after-a-detectable-fetal-heartbeat-is-set-for-consideration-by-louisiana-legislature.html

Congressional Record. (2018, September 27). Supreme Court Hearing Sexual Assualt Hearing. Retrieved from C-Span: https://www.c-span.org/video/?451895-2/supreme-court-nominee-brett-kavanaugh-sexual-assault-hearing-judge-kavanaugh-testimony

Cross, J. (2019, February 11). The Daily Tarheel. Abortions After 12 Weeks Could Be Ilegal In North Carolina If New Bill Passes. Retrieved April 11, 2019, from https://www.dailytarheel.com/article/2019/02/nc-abortion-ban-0211

Federal Bureau of Investigation. (2019, April 11). United States Crime Statistics 2007-20017. Retrieved from Federal Bureau of Investigation Crime Data Explorer: https://crime-data-explorer.fr.cloud.gov/explorer/national/united-states/crime/2007/2017

Guttmacher Institute. (2019, April 7). State Policy-Insurance Coverage for Contraceptives. Retrieved from Guttmacher.org: https://www.guttmacher.org/state-policy/explore/insurance-coverage-contraceptives

Guttmacher Institute.org. (2019, April 7). State Policy Sex and HIV Education. Retrieved from Guttmacher.org: https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education

Lam, K. (2019, April 11). North Dakota Becomes Third State to Ban Dialation and Evacuation Procedure. USA Today. Retrieved April 11, 2019, from https://www.usatoday.com/story/news/nation/2019/04/10/north-dakota-abortion-procedure-dilation-evacuation/3429483002/

Laurie Sobel, A. S. (2019, April 7). Kaiser Family Foundation State and Federal Contraceptive Coverage Requirements. Retrieved from KFF.org: https://www.kff.org/womens-health-policy/issue-brief/state-and-federal-contraceptive-coverage-requirements-implications-for-women-and-employers/

McDevitt, D. J. (2016, July 22). Condom Laws. Retrieved April 7, 2019, from RipnRoll.com sex education blog: https://www.ripnroll.com/blogs/sexual-education/condom-laws

NCSL.org. (2019, April 7). Emergency Contraception State Laws. Retrieved from National Center for State Legislation: http://www.ncsl.org/research/health/emergency-contraception-state-laws.aspx

Princeton University. (2019, April 7). Emergency Contraception. Retrieved from Princeton.edu: https://ec.princeton.edu/questions/state-pharmacy-access-list.html

Public Opinion on Abortion. (2019, April 6). Retrieved from Pew Forum.org: https://www.pewforum.org/fact-sheet/public-opinion-on-abortion/

Rau, A. B. (2019, March 14). What Arizona's Latest Abortion Law Really Does. The Republic, p. 2017. Retrieved April 11, 2019, from https://www.azcentral.com/story/news/politics/legislature/2017/03/14/what-arizonas-latest-abortion-bill-really-does/98606122/

National Women's Law Center. (2019, April 7). Providing Emergency Contraception to Sexual Assualt Victims. Retrieved from Washington Womens Law Center.org: https://nwlc.org/wp-content/uploads/2015/08/providing_ec_to_sexual_assault_survivors_factsheet_6-28-13.pdf

Weiss, J. (2019, January 20). What is the Future of Abortion Restrictions in Florida. WLRN. Retrieved April 11, 2019, from https://www.wlrn.org/post/what-future-abortion-restrictions-florida