US is the only developed nation where rate of pregnant mother deaths is rising (a reprise from 2015)

The rise in maternal mortality in the United States has been hitting the headlines, especially as it relates to Louisiana leading the way. Senator Bill Cassidy is getting flak, rightfully so, for trying to minimize the problem focusing on taking the African-American mothers out of the equation. Their deaths are an important part of this, but they are only a part, but deserve due diligence as to why just like every other race, income group, ethnic group, etc. We should look to things like – lack of healthcare access, fewer rural hospitals, food deserts and poverty as several of the causes. Yet, this is not a new problem, as I wrote this post seven years ago.

Recently, a very powerful article was written by Danielle Paquette in The Washington Post entitled “Why pregnant women in Mississippi keep dying.” A link to the article follows: http://www.washingtonpost.com/blogs/wonkblog/wp/2015/04/24/why-pregnant-women-in-mississippi-keep-dying/. While the article focuses its title on Mississippi, that is a metaphor for a national problem. The US is now the only developed nation where the rate of pregnant mother deaths is increasing. In 1987 only 7.2 pregnant women were dying per 100,000 births. That rate has more than doubled in 2013 to 18.5 deaths per 100,000 births. Our maternal death rate in childbirth is 3x the rate in Saudi Arabia and 2x the rate in the UK.

In Mississippi, it is far worse with 54.7 black mothers dying in childbirth out of 100,000 births and 29.3 white mothers dying per 100,000. There a number of reasons cited, but one of the key reasons is that Mississippi has not expanded Medicaid and have over 107,000 people who do not have access to healthcare coverage. Note, other reasons are cited, but not having health care coverage limits access to preventive visits that expectant mothers with care get.

As many know, I have been a broken record for the need to continue and improve the Affordable Care Act, which is working pretty well by a number of studies and has dampened cost increases with the Congressional Budget Office lowering health care projections three times due in part to the ACA. In fact, just yesterday at Congress’ request, the CBO and Joint Committee on Taxation noted that repealing the ACA would increase the deficit by $353 Billion (or $137 Billion when a new dynamic scoring approach is used). This seems to run counter to rhetoric of how harmful the law is. Here is a link to the article: http://www.msn.com/en-us/news/politics/obamacare-repeal-would-boost-10-year-deficit-by-dollar353b-cbo/ar-AAbQa2S?ocid=DELLDHP

But, we need to finish the job and completely implement the ACA in about twenty states, such as North Carolina, that have not expanded Medicaid to cover a key tranche of people under the ACA. It is not surprising, these predominantly southern states are seeing the worst child and mother health results. Several reputable health-related foundations (The Commonwealth Fund, Kaiser Family Foundation) and economic think tanks (RAND and Economic Policy Institute) have noted that not expanding Medicaid is actually harmful to people and this is more evidence of that assertion.

Please read these articles and, if you concur these are problems worth doing something about, reach out to your state legislators and US representatives and senators. Ask them to support the continuation of the ACA as the majority of Americans wish to happen. Ask the states who have not expanded Medicaid to do so as they are hurting people, rural hospitals and their own economies in not so doing. These issues are that important as people are the pawns in these political chess games and they bear the brunt of these decisions with their health and lives.

Are US hospitals in trouble?

Many hospitals, especially more rural ones, have been in trouble for some time. More on the rural hospitals later.

“More than 33% of all hospitals are operating on negative margins, according to the American Hospital Association,” per Michael Popke of Benefits Pro in a piece called “America’s hospitals facing ‘massive growth in expenses’.” Here are two select paragraphs from the piece that tell the gist of the story.

“Hospital employment is down approximately 100,000 from pre-pandemic levels, while hospital labor expenses per patient through 2021 were more than 19% higher than pre-pandemic levels. A new report from the American Hospital Association highlights the financial and operational toll the pandemic and inflation has taken on hospitals — concluding that more than one-third are operating on negative margins.

‘Hospitals and health systems have been nimble in responding to surges in COVID-19 cases throughout the pandemic by expanding treatment capacity, hiring staff to meet demand, acquiring and maintaining adequate supplies and personal protective equipment to protect patients and staff, and ensuring that critical services and programs remain available to the patients and communities they serve,’ notes the nine-page report released this month. ‘However, these and other factors have led to billions of dollars in losses over the last two years for hospitals.’”

Per an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

“Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

The rural hospital concerns predate the advent of the Affordable Care Act. Too many hospitals had high percentages of indigent health care costs, meaning people without insurance. If they were not funded by a county, the hospital was at severe risk of closing. Since fourteen states have still not expanded Medicaid under the ACA, the opportunity for getting paid did not increase and many have closed. And, the patients, employees and communities suffer.

Yet, a major part of this cost dilemma existed before COVID-19. The US has the most expensive health care system in the world, but we rank around 38th in health care quality. That is a pretty poor rate of return on one’s spend. Hospitals spent too much on technologies that need to be used. There exists a correlation between the ownership of a technology and its higher frequency of use. Yet, with COVID-19 and its aftermath, fewer elective procedures and tests were done in hospitals.

These issues need to be evaluated outside of the political lens and with data. Yet, that is not bound to happen. It would at least be helpful to see more people covered with full Medicaid expansion, but that has been politicized for zero-sum game reasons, not to actually help people. It would be helpful to see Medicare expanded, at least down to age 62 from 65. As Medicare works reasonably well, I would like to see it go lower, but whatever we do, it should be evaluated on its results, not a politician’s beliefs.

If people think I am unfairly picking on politicians, it would not be a stretch to say most politicians do not know a whole lot about health care. We saw this with the atrocious “throw stuff against the wall” repeal and replace discussion in 2017 by the thirteen Republicans, which came within one vote from passing the Senate. That would have screwed about 20 million Americans. Senator John McCain gave it a thumbs down vote for its lack of veracity and its poor protocols on evaluation.

And, we saw it with the discussions and passing of the ACA, which Republicans refused to vote for which is strange since it has several Republican ideas in it from Romneycare in Massachusetts, when Mitt Romney was governor there. The ACA is not perfect, but at least we should fully implement it and shore up its deficiencies. It is only people’s lives.

Medical debt impacts 23 million Americans per Kaiser study

In an article called “The burden of medical debt in the United States” by Matthew Rae, Gary Claxton, Emma Wager, Cynthia Clark, Jared Ortaliza, and Krutika Amin, the results of a Kaiser Family Foundation (KFF) are noted. Per the article, a link to which is below, the following conclusion can be drawn:

“We find that 23 million people (nearly 1 in 10 adults) owe significant medical debt. The SIPP survey suggests people in the United States owe at least $195 billion in medical debt. Approximately 16 million people (6% of adults) in the U.S. owe over $1,000 in medical debt and 3 million people (1% of adults) owe medical debt of more than $10,000. Medical debt occurs across demographic groups. But, people with disabilities, those in worse health, and poor or near-poor adults are more likely to owe significant medical debt. We also find that Black Americans, and people living in the South or in Medicaid non-expansion states were more likely to have significant medical debt.”

Several years ago, I cited a study that noted medical debt was the number one reason for bankruptcy by individuals, so the above result is not a surprise. The groups that are most exposed are non-Hispanic Blacks at 16% and people in the age 50 to 64 demographic at 12%. Some of the reasons for this age group being higher is Medicare does not kick in until age 65, people are getting downsized in that group and employer retiree medical benefits have largely gone away.

I posted a piece from Politico the other day about rural health care suffering. An important reason is the fourteen states who have not expanded Medicaid to those below a certain poverty level. This has led to more rural hospitals closing and exposed people who do not have coverage to higher medical debt or forsaking care all together. The debt comes with people waiting until they are a train wreck before going to the ER, a more expensive place to get care.

One of the things I have found in my consulting experience as well as patient and care taking experience, access to health care is critical to a person’s health. The ability to get preventive care before the train wrecks also lowers the cost while improving one’s health. In the US, one of our warts is we are the most obese country in the world per the World Health Organization. We have supersized ourselves to earn that mantel. We must get ourselves on a better path before it becomes too late.

Access to care is key to getting on that better path, but making it a more affordable journey. When people say we have the best health care system in the world, that simply is not borne out by the data – we have the most expensive health care in the world; we rank in the low thirties in health care outcomes. We must use the system more wisely. All of us.

Rural Health Care is suffering (and COVID-19 has made it worse)

In an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

A key reason is the closing of rural and small town hospitals that has severely impacted immediate health care. A key paragraph from this article is telling:

“Of the 50 counties with the highest Covid deaths per capita, 24 are within 40 miles of a hospital that has closed, according to a POLITICO analysis in late January. Nearly all 50 counties were in rural areas. Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

These hospital closings are not new nor did they just happen. The financial difficulties predate the passage of the Affordable Care Act. In essence, a significant portion of the cost of running these hospitals went toward indigent care, meaning people without insurance. In some cases, it was over 50% and even as high as two-thirds of the hospital budget. This meant some of the revenue may be reimbursed by the local county, but if the county was in financial trouble or this was a private hospital, the hospital was out of luck.

The ACA brought with it the expansion of Medicaid, should a state opt in to cover people. The federal government would reimburse the state those costs for three years and then drop to 90% thereafter. All but fourteen states have so expanded. Per the non-partisan Commonweath Fund, Medicaid expansion helps the state economy, rural health care and the people in those locations. Former Republican presidential candidate John Kasich called Medicaid expansion a “no brainer” when he was governor of Ohio.

And, these hospitals are usually a major employer in these towns. So, when one closes, a lot of revenue leaves the town budget and economy. Belhaven, NC Mayor Adam O’Neil, a Republican, pleaded with the state leaders to expand Medicaid, but to no avail. So, he walked to Washington, DC to plead his case there. It should be noted that North Carolina remains as one of the fourteen states who have not expanded Medicaid.

As a retired benefits consultant, manager and actuary, I know the ACA is not perfect and could use some shoring up. But, a key reason for the ACA is patients need access to care and hospitals need to get paid for services rendered. If a patient has health care insurance, he or she will seek more preventative measures to stave off problems. Plus, he or she will seek care if needed, rather than avoiding it.

All of the above greased the skids for a problematic response to COVID-19. Without hospitals close by, people would forego care until it was too late. Plus, coordination of care with doctors to do triage and offer vaccines is hindered.

The ACA is not perfect, but it has improved access care for many people. I have written before about some suggestions to improve it. Yet, in fourteen states, the ACA still has not been fully implemented and in many of those states, they lag other states on health care results per the Commonwealth Fund. Expansion of Medicaid could be a major step.

https://news.yahoo.com/public-health-disaster-shuttered-hospitals-110000044.html

Our children deserve better – a repeated pre-pandemic clarion call

The following post was written a couple of years ago. Although the pandemic has rightfully gotten our attention, this story bears repeating.

Two time Pulitzer Prize winner Nicholas Kristof wrote an editorial earlier this week in The New York Times called “Our children deserve better.” It is a clarion call to our nation showing the plight of kids in America.

Here are a few quotes to frame the issue:

“UNICEF says America ranks No. 37 among countries in well-being of children, and Save the Children puts the United States at No. 36. European countries dominate the top places.

American infants at last count were 76 percent more likely to die in their first year than children in other advanced countries, according to an article last year in the journal Health Affairs. We would save the lives of 20,000 American children each year if we could just achieve the same child mortality rates as the rest of the rich world.”

“Half a million American kids also suffer lead poisoning each year, and the youth suicide rate is at its highest level on record….The Census Bureau reported this week that the number of uninsured children increased by 425,000 last year.”

These are different views and sources of the threats to US children that note we have a problem. Another source I read a couple of years ago noted America has a much higher maternal mortality rate at child birth than other civilized countries, which further endangers children as well as the mothers.

Yet, these issues are not being discussed in the halls of government. We have a poverty problem in our country with too many living in or just above poverty levels. We have not expanded Medicaid in fifteen states* whose numbers are worse than these national numbers per capita. We have not addressed our national water crisis which has a Flint, MI like exposure to lead in too many cities and a volume of available fresh water issue in other places. We have not invested as we should to diminish crime and provide more opportunities for jobs in disenfranchised areas. There are several pockets of success that can be emulated in more cities.

We also need to address better gun governance, especially with the number one gun death cause by far being suicide and a non-inconsequential accidental gun death rate. And, we have not dealt with the continuing and rising exposure to technology and artificial intelligence which have taken and will take even more jobs in the future. Finally, there is that climate change thing we need to deal with.

These are real problems. And, they will get worse. Data driven analysis of causes and solutions are needed. They are both multi-faceted. Investing more now, will save huge amounts later. This is not just an urban issue, it is rural one as well. The opioid crisis is rampant in these impoverished rural areas, for example.

None of the solutions will fit on a bumper sticker. And, political attempts to oversimplify issues should be questioned. Here is an easy contradiction to spot – if people believe gun deaths are a mental health issue, then why the effort to eliminate or not expand mental health benefits?

Please make your legislators aware of these issues and ask pointed questions. These questions deserve answers, not bumper sticker slogans. These concerns deserve to be talked about, studied and acted upon.

*Note: The number of states who have not expanded Medicaid is now twelve. Here is a link to a tracking of the states who have and have not. What puzzles me is this change would help people in rural areas, which tend to vote more conservatively. So, not expanding Medicaid hurts health access, but also rural hospitals and economies, with the federal government funding 90% of the cost. As former Republican governor of Ohio and presidential candidate John Kasich said, Medicaid expansion is a “no brainer.”

Near universal health coverage achieved in six states and DC

An article by Michael Rainey of The Fiscal Times (see link below), called “How six states achieved near universal coverage” noted the success of covering at least 95% of their people. These six states are Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island and Vermont. The District of Columbia also fits the bill. Per the article:

“A half-dozen states and the District of Columbia have health care insurance rates of over 95%, achieving near-universal coverage. Three researchers at the University of Pennsylvania — including Ezekiel Emanuel, a key architect of Obamacare — said Monday that the Affordable Care Act has everything to do with those results.

Here’s how the states achieved such high insurance rates, according to the authors:

Expanding Medicaid: States that expanded their Medicaid programs as allowed under the ACA had about half the uninsured rate (6.6%) in 2018 as states that did not do so (12.4%). ‘Nearly 5 million people would gain health insurance if the remaining 14 states expanded Medicaid,’ they write.

Extending enrollment periods: High-coverage states countered the Trump administration’s efforts to shorten enrollment periods and reduce informational assistance.

Lowering premiums: States enacted additional subsidies and reinsurance programs to keep premiums low, a crucial factor in maintaining insurance coverage from year to year.

Simplifying options: Some states limited the number of options available to counteract “choice overload,” which can reduce signups through consumer paralysis.

Maintaining individual mandates: Five low uninsured states maintain some kind of individual and employer mandates, which may help persuade healthy people to sign up.

The lesson, the authors say, is that near-universal health coverage can be achieved without national legislation. ‘While it is easy to dismiss the ACA and focus on the promise of Medicare for All, there is a more straightforward path to universal coverage,’ they write, ‘adopting a handful of relatively simple policies and programs at the state level can ensure health insurance coverage for nearly all Americans.’”

This article echoes what can be achievable if Medicaid is expanded and the other above steps are taken. The three states who drag the results down for the country – Texas, Florida and Georgia – did not expand Medicaid nor run their own Healthcare exchanges. Of the six states over 95%, it should be noted Iowa and Hawaii use the federal Healthcare Exchange, while the other four run their own exchanges.

I have long said Medicare for All is something to be explored, but it requires detailed analyses (and time) of its costs and impact. In the interim, I have strongly advocated improving the Affordable Care Act. The goal is access to care, in my view. The employment paradigm has been changing for some time, where fewer full-time workers are being used than before. We are seeing several industries move to a largely part-time workforce, such as in the retail, restaurant, and hospitality industries. We have seen contractual employment continue as well as the growth of gig economies. Health care access needs to come from somewhere.

What I do not care for is the hyper-politicization of this topic. Republicans (including the president) have actively sabotaged the Affordable Care Act, cutting funding to insurers, not mentioning the negative talk about it. It has still survived. Some Democrats choose to throw progress out and go full bore with Medicare for All. Again, that is a detailed undertaking and no candidate can accomplish this without buy-in from both parties.

So, let’s improve what we have. States who have not expanded Medicaid have been economically short-sighted and harmed their citizens. I have argued for repaying insurers who were harmed by the reneging on funding commitments, inviting them back into markets. Where choice is not available, introduce a Medicare option. I would also lower the eligibility for Medicare to age 60 or 62.

These are practical options that may move the needle upward like in those six states. Let’s talk about that.

https://finance.yahoo.com/news/6-states-achieved-near-universal-224827646.html

Rural hospitals closing at an alarming rate

Rural hospitals in trouble is not a new topic, but the significant increase in closings and risk of such is finally getting some attention. The issue for years has been the large percentage of a rural hospital’s budget that went unpaid due to patient debt and indigent care. In some hospitals, the percentage of these two items is more than 1/2 of the budget.

Per a February, 2019 article in Modern Healthcare called “Nearly a quarter of rural hospitals are on the brink of closing” by Alex Kacik: “Twenty-one percent of rural hospitals are at high risk of closing, according to Navigant’s analysis of CMS data on 2,045 rural hospitals. That equates to 430 hospitals across 43 states that employ about 150,000 people and generate about $21.2 billion in total patient revenue a year.

Hospitals are often the economic drivers of rural communities. Per capita income falls 4% and the unemployment rate rises 1.6 percentage points when a hospital closes, a related study found. Ninety-seven rural hospitals have closed since 2010, according to the University of North Carolina Cecil G. Sheps Center for Health Services Research.

They also broke the impact down by state, revealing that half of Alabama’s rural hospitals are in financial distress, the highest percentage in the country. At least 36% of the hospitals in Alaska, Arkansas, Georgia, Maine and Mississippi are in financial jeopardy.”

Most of the states in trouble chose not to expand Medicaid, but there are some who did or are now doing so. Per several studies by The Commonwealth Fund, RAND Corporation, Economic Policy Institute and George Washington University, expanding Medicaid would help patients, state economies and rural hospitals. Why? It would allow these hospitals to get paid and paid closer to the time of service reducing accounts receivables. Getting paid has an echo effect on employees and consumers.

This issue was brought home by two Republicans pleading with their party to acquiesce in states like North and South Carolina that did not expand Medicaid. GOP Governor John Kasich of Ohio, who ran for President, said Medicaid expansion is a “no brainer” and would add over $13 billion to Ohio over several years. Yet, the most dramatic plea was from Adam O’Neal, a GOP Mayor of a North Carolina town called Belhaven.

After failing to get the GOP majority in Raleigh to help save his town’s Vidant Pungo Hospital that served 20,000 people, he walked 273 miles to Washington, DC over 14 days. “You can’t let rural hospitals close across the country. People die,” O’Neal, told Modern Healthcare in 2014. Unfortunately, Vidant Pungo closed later that year (note a non-ER clinic opened in 2016).

You can add my pleas for help back then (and now). Folks, this stuff is real. I do not care if your tribe is blue, red, purple are chartreuse, hospital closings impact people’s lives and people’s livelihoods. Closings also hurt their community’s economy. My strong advice is for legislators to stop political posturing and do something. I do not care who wins or loses a political game. Stop focusing on keeping your job and do your job. You could start by expanding Medicaid, joining the other 36 states.

Debt collections declining in states who expanded Medicaid

Since not every state fully implemented the Affordable Care Act, data now exists that can contrast those who did with those who did not. Thirty-one states and the District of Columbia have expanded Medicaid, with nineteen states still remaining.

For those who do not follow this closely, the ACA uses Medicaid expansion as the vehicle to deliver health care coverage for people beneath 138% of the poverty level. The federal government would front 100% of the cost for three years, eventually declining to 90% thereafter. Yet, the Supreme Court said states could opt out of this feature, which 19 still have done so.

Per the attached article, The Federal Reserve Bank of New York in a study finds a benefit to people in states where Medicaid expansion occurred is debt collections have declined. I have written before that the principal reason for personal bankruptcy is medical debt. The study’s authors note:

“U.S. counties that had a particularly high uninsured rate prior to the implementation of the Affordable Care Act have seen the per capita collection balance fall if their state embraced the Medicaid expansion. If not, the collection balance continued to climb.”

Yet, in states where Medicaid was not expanded, debt collection is noticeably more in comparison. Per The Commonwealth Foundation, Kaiser Family Foundation, RAND Corporation, Economic Policy Institute and a George Washington University study, expanding Medicaid helps those in need, helps a state’s economy and helps hospitals, especially rural ones who have high indigent and uninsured costs. The hospitals in Medicaid expanded states are seeing fewer uninsured patients and seeing better operating margins. Now, evidence shows it keeps more folks out of bankruptcy.

Former Ohio Governor John Kasich, who was the most reasonable GOP presidential candidate in the view of many, said expanding Medicaid was a no brainer. He said it would bring $13 Billion to his state over the next several years when announced. It also helped his constituents. During the campaign he remained a supporter of Medicaid expansion, which swam against the GOP tide. It is hard to be a lone advocate in a sea of political animosity.

It is past time for leaders in the remaining states to stop thinking like party representatives and start thinking like financial stewards. Several states gave serious consideration, such as Oklahoma, Alabama, Idaho and Wyoming, to expanding during the spring, but in spite of strong data showing its benefits to the state, its hospitals and people, Republican animosity toward the ACA defeated the proposals. Medicaid expansion would help many, including those Republican constituents in poverty living In rural areas. It should be noted that these are the same folks who feel their party is not doing more for them.

Make a move legislators and help all your people, but especially your constituents.

http://www.benefitspro.com/2016/06/13/states-that-embraced-health-care-reform-seeing-les?eNL=575f314b140ba09f23187fc4&utm_source=BPro_Daily&utm_medium=EMC-Email_editorial&utm_campaign=06142016

Affordable Care Act – remind folks to sign up by February 15

The Affordable Care Act continues to build its resume, even though there are some who try to ignore this growing success for political reasons. That is unfortunate as many who have not considered the ACA are shortchanging themselves due to available subsidies, which are favored by the majority of Americans per the Kaiser Family Foundation. More on this later.

It troubles me when I see people who are part of fundraising events to raise $150,000 or more to pay for medical bills for an injured or sick child because they lacked healthcare insurance. If these folks had signed up for the ACA, the only money they would need is for the out-of-pocket limit which usually run in the $5,000 to $20,000 range depending on the plan selected. As I have noted before, the number one reason for personal bankruptcy in the US is no or poor healthcare insurance. Yet, it is not too late, as they can still sign up for care since coverage is guaranteed, which previous policies did not offer.

With three weeks to go in the ACA’s current exchange enrollment season, exchange enrollment has hit 9.6 million passing the President’s expectations. The exchange enrollment will likely push toward the Congressional Budget Office (CBO) target of 12 million by the middle of next month.  It should be noted this does not include enrollment under Medicaid in the majority of states who did expand Medicaid, which will only improve with more states considering such expansion.

Further, the non-partisan CBO has for the second time reduced its projections of future medical costs as a result of dampening costs due in part to the Affordable Care Act. As an actuary and former benefits consultant and manager, having more folks covered will help further dampen costs as they seek treatment and get medications before they become eventual train wrecks. Plus, by seeing doctors and nurses in advance, the long term costs are further dampened as they are being served in the more cost-effective place and not in an Emergency Room in a crisis.

But, back to the Kaiser Family Foundation survey from January. Many may not realize that some strident opponents have brought a lawsuit that questions the ability of the federally run exchanges to offer the subsidy. The federal exchanges had stepped up to cover 37 states, when some states asked them to do so. The US Supreme Court will rule on this later in the year. I do not anticipate that they would rule unfavorably, but stranger things have happened. If they did about 10 million Americans would be screwed, sorry for the use of the most appropriate term. Yet, per Kaiser, what would Americans want in that case:

  • 64 percent say Congress should pass a law making subsidies available in all states;
  • 40 percent of Republicans favor such a law, with a solid majority of Democrats and Independents supporting such legislation;
  • 59 percent of residents in the healthcare.gov states say they would want their state to act to operate its own exchange;
  • By party declaration, 61 percent of Democrats, 63 percent of Independents and 51 percent of Republicans favor a state exchange in those now served by the federal exchange.

Given the fact there is a cost to running an exchange, many of the states asked the federal government to take the lead. In fact, a significant number of state attorney generals have written to the US Supreme Court to not rule against the subsidy.

With all of its complexity and communication challenges, which is partly due to Americans not understanding healthcare insurance, in general, the ACA is building a resume of success. This Congress should heed Americans wishes to improve it where possible, but accept that it is showing success. And, the remaining state legislatures should expand Medicaid as it would help many residents in need, help their economy even further, and keep rural hospitals afloat to serve.

A potpourri of news items

While a few thoughts bounced around as potential themes, I felt it would be best to highlight a few items of note, in a world of many to choose from. In no particular order:

Ukraine troubles continue – One of the things that does not get stated in the downing of the Malaysian airplane is the pro-separatists do not have any planes, so why would the Ukraine military be firing in the air? The evidence points the finger where the missile was launched from and the group that says it had no hand in it is not letting people get to the site to investigate. And, the artillery launcher was moved, presumably back to Russia. Call me crazy, but when your arguments are contradicted by actions, then your credibility lessens. Putin has not learned this yet either. Folks, get to the table and negotiate a settlement to cease innocent people being killed and before your story falls apart. Plus, while I understand economic sanctions in this case as an alternative to military options, in general, I don’t like them, as they tend to punish the wrong people for leaders’ actions.

Israel, Hamas and Gaza – In my simple view, a country has a right to defend itself, but Israel has gone a “bridge too far” and is looking poor for civilian deaths. The UN is correct to assert their position and the violence on civilians and children must end. Hamas should also get poor marks for hiding among the civilians and setting the stage for pawns to be killed, as well as not acknowledging the right for the other to exist. Yet, the conditions are ripe for a group like Hamas to survive. Reasonable leaders (on both sides) need to advocate for a cessation to the violence which is killing its people. Reasonable leaders need to push for finding a way to co-exist. Reasonable leaders need to find ways to stop marginalizing people and look for ways they can thrive, live in peace, raise families and practice their religion. If they do not, then both sides are destined to live in an environment where innocent people are in danger and killed.

Afghanistan election is important – A major step forward for Afghanistan is still in the works. The Presidential vote recount is important to get it right and pass muster. This is the first election post Karzai and it needs to be successful regardless of the winner. The peaceful transition of power is a major element of a sustainable government. This is why the Taliban is in such a dither not to let it happen.

Medicaid expansion push gets a practical conservative voice – Please check out Dana Milbanks’ editorial article on a conservative GOP Mayor in North Carolina marching to Washington to advocate for saving a closed rural hospital in his town. A woman died because of this closing, as she could not make it to the next town in time, which was 75 minutes away. He had reached out to the North Carolina GOP leadership and was told they could not support anything to do with Obamacare. He said it plainly, this is not a political issue, this is an issue about people dying because we don’t have a hospital near by.

Kudos to Senator Bernie Sanders and Representative Jeff Miller for collaborating – I mention their efforts in my previous post, but want to highlight how legislation used to and is supposed to work. Sanders is an Independent, who caucuses with Democrats and Miller is a Republican, yet they said failure to get some action to help our veterans is not acceptable. I hope it catches on as a trend. Again, as you vote this fall, if a candidate advocates strident ideology at the expense of collaboration, a “my way or the highway view,” show them the highway.

Treat others like you want to be treated, especially refugee children – America has had an immigration problem for a while, but legislators would prefer not to act, even though there are votes today in the House to pass the bi-partisan Senate bill passed last year. They also complain about securing the border, yet won’t fund filling open border patrol positions. Irrespective of this, people should not punish children, with some screaming at them, for our own failures. A recent Religion Polling survey noted that 75% of Americans want us to take in these children. We have already made this a political chess game. Let’s stop making it a game and show some stewardship and heart. My friend George Dowdell notes in his blog* about the concept of being a Red Letter Christian, meaning Christians should follow the words that Jesus spoke. So, WWJD?

Same-sex marriage train continues down the track – 19 states now allow same-sex marriage and fifteen more have ruled in favor, but are awaiting the appeals process. The Fourth Circuit US Court of Appeals has ruled in favor of same-sex marriage over the Virginia case, but their jurisdiction includes South and North Carolina. The Attorney General in NC said after the ruling this week, that he will no longer fight the current court cases, since the appellate court has spoken. I said a few posts ago, this train has left the station and eventually all states will allow same-sex marriage, as to do otherwise is discriminatory and unconstitutional. So, I repeat the question I asked then, if you are against same-sex marriage, where do you want to spend your time?

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There are many other topics worth talking about. I would love to hear your thoughts on these and other topics. Thanks, in advance, for your comments. Note, you can check out George Dowdell’s terrific post on Red Letter Christians with this link: http://georgedowdell.org/2014/07/28/take-seriously-what-jesus-said/#more-3033