Tag Archives: Affordable Care Act

How to Find Health Insurance


Do you have health insurance? Even if you do, do you still feel like you pay a lot for your medical expenses? Here’s the point: do you know what the #1 cost of personal bankruptcy is in the U.S.? Medical bills. Want to know a very easy way to rack up huge bills? That would be using the emergency room as your source of care. The average cost of a visit to the ER for over 8,000 patients across the U.S. was $2,168, according to a recent study funded by the National Institute of Health. Look at these average costs (the interquartile range (IQR) represents the difference between the 25th and 75th percentile of charges, looking at the wide discrepancy in charges).

Can you afford this without insurance (or even with insurance, given your co-pays and deductibles)? This Straight, No Chaser post is the first of your empowerment series. Remember, health empowerment starts with knowledge. Remember it’s the above types of charges that you’re trying to avoid.

Did you know that according to the Census Bureau, there are still about 27.5 Americans without health insurance as of 2018 (that number was estimated to be as high as 50 million prior to the implementation of the Affordable Care Act, aka Obamacare)? 2018 was also the first year since 2008-09 for which there was an increase in this number. Draw your own inferences about why this is the case (or just look at the below picture!).

Insurance Options

Where do you start if you don’t have insurance? What should you do if you have insurance? What if it’s an emergency? Let’s go through a series of options you have available to you that you may not know how to enlist.

How do you choose affordable insurance coverage if you don’t have a job, your job doesn’t provide health benefits, or if you just don’t have enough money to afford it? Work through the following steps.

  1. Look For Coverage Through Your Spouse or Domestic Partner. If you have a spouse or partner, there’s money to be saved by piggybacking off the other’s coverage. Explore this option before accepting a new plan that requires you to pay more.
  2. Explore the Health Care Marketplace as Your First Stop. This is especially the case if you’re otherwise uncovered or are an entrepreneur or small business owner. It’s also especially applicable if you have a pre-existing medical condition. Go to healthcaregov.org for details.
  3. Medicaid: In more than half the US, state Medicaid expansion accompanied the Affordable Care Act. This has resulted in the number of people qualified to receive Medicaid increasing dramatically. It’s also included many above the poverty line who previously hadn’t been eligible. Google your state insurance commissioner for your specific set of qualifications.
  4. Medicare: You can qualify for Medicare if you receive Social Security disability benefits or if you’re age 65 or older. Check with the Social Security Administration for your eligibility.
  5. Consolidated Omnibus Budget Reconciliation Act (COBRA): COBRA is another short-term coverage option. It might be for you if you’ve been laid off or aren’t working. It’s especially appropriate if you had insurance through your former job or otherwise participated in a group health insurance plan. This is great for access but is a more expensive option than the health care marketplace.
  6. Workers Compensation: If you are being treated for a workplace injury, your state’s workers’ compensation program might have health care solutions for you.

Less Obvious Insurance Options

  1. Short-Term Health Insurance Coverage: Short-term coverage is available! Think about this if you need to avoid gaps while searching for other options. A simple Google search will point you in the right direction in your state.
  2. High Deductible Health Plans: A high deductible “emergency” policy is another way to maintain a low-cost health insurance plan. However, it’s akin to making a bet that you won’t get ill. Maintaining a Health Savings Account (HSA) for smaller health issues will probably save you money in the long run. 
  3. Group Insurance from Organization Memberships: If you belong to any kind of membership organization (e.g. an alumni association, professional organization, business bureau, independent worker associations), it’s worth asking if they have a health insurance plan. These also provide reduced health insurance premiums for their members. You don’t have to go the route of employer-provided insurance.
  4. Group Health Expenses Sharing Plan: These health expenses sharing plan involves a group of people pooling money together to pay each other’s health care costs. They operate a bit like their own insurance company. Members’ pooled contributions are invested and are usually reserved to pay major medical expenses. These plans aren’t typically used for basic day-to-day health costs like checkups or small procedures. Group health expense sharing plans aren’t insurance plans, so they’re not regulated in the same way as insurance. Look into the history of any of these plans before you join one.
  5. Health Care Sharing Ministries (HCSMs): A health care sharing ministry (HCSM) is another example of a group of people with shared beliefs creating a health expenses sharing plan. An HCSM is a non-profit entity, so again, it’s not health insurance and it’s not regulated in the same way. This alternative to insurance often include provisions that accommodate the beliefs of the group. As a result, procedures (e.g. abortion) that are deemed objectionable would not be covered. 
  6. Health Insurance Discount Cards: These aren’t insurance options but a way of obtaining discounts on medical services. They provide low-cost health services in exchange for a membership fee. They also don’t offer any medical reimbursement but lower your costs when you use the services of members participating in the plan. 

These are options. However, the question many of you have remains unaddressed: what if you believe you can’t afford any of these? Well actually you can; some of the above have eligibility based on financial status, such as Medicaid and Medicare. It’s up to you to do the work and discover where you’re eligible.

Furthermore, this is why health prevention is so important. This is why the rest of the health empowerment series focuses on what you can do to swing the pendulum away from waiting to need sick care toward being proactive with preventive and self-care. Stay tuned.

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Feel free to ask your SMA expert consultant any questions you may have on this topic. Take the #72HoursChallenge, and join the community. As a thank you, we’re offering you a complimentary 30-day membership at www.72hourslife.com. Just use the code #NoChaser, and yes, it’s ok if you share!

Order your copy of Dr. Sterling’s books There are 72 Hours in a Day: Using Efficiency to Better Enjoy Every Part of Your Life and The 72 Hours in a Day Workbook: The Journey to The 72 Hours Life in 72 Days at Amazon or at www.jeffreysterlingbooks.com. Receive introductory pricing with orders!

Thanks for liking and following Straight, No Chaser! This public service provides a sample of http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK. Please share our page with your friends on WordPress! Like us on Facebook @ SterlingMedicalAdvice.com! Follow us on Twitter at @asksterlingmd.

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In The News: What “Medicare For All” Means and Might Look Like


Medicare For All

In the news is a proclamation from no fewer than three prominent candidates for President that they would seek to implement “Medicare For All” as America’s health care system. Let’s go Straight, No Chaser and review what that might mean. Let’s frame the conversation around three frequently expressed concerns. First, let’s remember that no actual proposal exists. Therefore, what Medicare For All may end up looking like is subject to a wide range of possibilities.

“Medicare For All” means socialized medicine.

Actually it doesn’t. If you think it does, you don’t understand the definition of socialized medicine. In an actual socialized medicine paradigm, everything is owned and/or paid for directly by the government. This includes the hospitals, the physicians and everything down to the equipment. That is not what Medicare is. Furthermore, it is not what Medicare For All would be. Medicare is an insurance program and a safety net. Also, it is a means of establishing guidelines and regulations. As such, Medicare For All (MFA) would enroll everyone in the nation under a single health care plan. Medicare would set prices for reimbursement and establish your tax burden.

It is incredibly unlikely that the individual cost of your care would be greater than the current annual burden of insurance. These current costs are just under $11,000/person. Remember, the drive for profits (most notably of insurance companies) would go away. This represents a lot of the current expense of health care. Furthermore, under Medicare For All, you’d get to keep your physician! All physicians would have to accept Medicare because there would only be a single payer. As a result, the lasting criticism about the Affordable Care Act wouldn’t be in play.

Is this good or bad?

One wonders about the public health impact of Medicare For All and a patient’s point of view? Remember, we typically look at these things through the prisms of quality, access and cost. Objectively, you’d have to think there are significant opportunities for improvement. It is worth exploring these opportunities instead of rejecting them out of hand.

  • Quality

Regarding quality, the U.S. currently is not doing a very good job at producing health care outcomes. Our current system is somewhere in the mid-30s when compared with the rest of the world. Furthermore, if you’re one of the 150 million Americans who currently enjoy (or at least prefer) your current insurance arrangement through your employee, take heed. Regarding quality, today’s Medicare isn’t likely to be tomorrow’s Medicare For All product. Medicare has been rather good at compelling specific outcomes. With implementation of a single payer system, convenience and quality would like improve beyond today’s standard.

  • Access

Regarding access, there are still approximately 30 million Americans without any health care. This number is down from approximately 50 million prior to implementation of the Affordable Care Act. So for about 15% of the country who otherwise wouldn’t have insurance, the immediate answer would become MFA is infinitely better than the status quo. Lack of access would be completely eliminated under MFA. This would be especially pleasing to those with pre-existing conditions. The conversation about cost is addressed below as a separate question.

“Medicare For All” means eliminating the current insurance company structure in the United States.

Although Sen. Kamala Harris stated as much as part of her platform, that occurrence doesn’t have to be the case. There is no reason why MFA couldn’t represent a “public option” for everyone. The key here would be the financial part. Let’s assume we allowed private insurance to remain for those wanting to pay for it. That’s possible, even while allowing the public option existed for everyone, whether or not they chose to utilize it. This paradigm would conceivably work.

However, the immediate problem would be both private insurance and MFA would become more expensive. Insurance premiums are largely determined by the number of participants in the system. The more people enrolled in a program allows costs to be pooled and reduced. Furthermore, we would predict that those opting out of MFA would still be required to share the tax burden of MFA. Basically, if you want the new system’s costs to explode, allow it to be something providing care only for the indigent and those otherwise unable to pay for private insurance. So under this scenario, those clamoring for private insurance would likely pay higher premiums to the private insurance company (because of less enrollees) and still having to pay a hefty MFA tax.

“Medicare For All” would bankrupt the country.

Even without doing a financial analysis (which isn’t possible because no actual proposal has been submitted), this has to be a preposterous supposition. To be fair, the United States does spend 17% of its gross national product (GNP) on health care. Disrupting the current system would cause disruption of both the clinical and financial aspects of the health care system – and a large segment of the American economy as a consequence.

On the other hand, the United States is alone in the world in spending 17% of its GNP on health care. The next most expensive system in the world (as measured by percentage of GNP) is France. Amazingly, they spend only approximately 11% of GNP on health care. What this means is there are tremendous efficiencies to be had by reforming the American health care system/industry. These efficiencies would result in tremendous savings.

The necessary next question is “Would you trust the government (or more specifically an expansion of Medicaid) to create those efficiencies and maintain a high quality of medical care and health care outcomes?” Indeed, this could go horribly wrong. However, it could be transformative for an incredible number of Americans. Which of the issues of providing health care to people vs providing profits to the healthcare industry will win? It is on these last two questions that the debate will rage on.

There’s More!

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Ask your SMA expert consultant any questions you may have on this topic. Also, take the #72HoursChallenge, and join the community. Additionally, as a thank you, we’re offering you a complimentary 30-day membership at www.72hourslife.com. Just use the code #NoChaser, and yes, it’s ok if you share!

Order your copy of Dr. Sterling’s books There are 72 Hours in a Day: Using Efficiency to Better Enjoy Every Part of Your Life and The 72 Hours in a Day Workbook: The Journey to The 72 Hours Life in 72 Days at Amazon or at www.jeffreysterlingbooks.com. Another free benefit to our readers is introductory pricing with multiple orders and bundles!

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A Dream of Equal Access to Health Care


On the day of observation of the life and legacy of Martin Luther King, Jr., we discuss applying his dream to equal access of health care.

mlk on health

On this national day of celebration, I always reflect on Dr. Martin Luther King, Jr.’s most famous comments on health care in America.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Using the sustained assault on the Affordable Care Act (aka Obamacare) in the US, it becomes as important as ever to revisit this premise.

Injustice in Health Care

Why would Dr. King say such a thing? Injustice in health care has taken many forms. Unfortunately, these result in predictably poor outcomes for those affected. We call these disparities in healthcare. Let’s begin by addressing the inequity in insurance coverage that formed the premise for the Affordable Care Act (aka Obamacare).

According to the Kaiser Family Foundation, in 2009-2010, when the Affordable Care Act (ACA; aka Obamacare) was signed into law, 41% of low-income adults were uninsured, and 45% of poor adults were uninsured. Contrast this with the fact that only 6% of those who make four or more times the poverty rate were uninsured. This pretty clearly makes the case that health care is a desirable asset for Americans who can afford it. Unfortunately, it is too often a choice that can’t be afforded for many. Furthermore, consider that 14% percent of white Americans were uninsured, while 22% of African-Americans were uninsured, and 32% of Hispanic Americans were uninsured. Whether you believe this is just a correlation, coincidence or reflection of something more damning, it is a situation that screamed to be addressed and improved.

Back in 2012 (immediately prior to implementation of the ACA), the Centers for Disease Control and Prevention (CDC) released a survey showing that more than 45 million U.S. residents didn’t have health insurance. Still even more people, 57.5 million, were uninsured for at least part of the 12 months before being polled. Be reminded that the total U.S. population is over 311 million.

The How and Why of Health Care Inequity

Please take a moment and ponder the enormity of the numbers just presented. It begs the question “How can such be allowed to exist?” Dr. King’s comment begged the same question. Unfortunately, the answer is the American health care system isn’t built on producing equality of access or outcomes. You’ve heard me say before that the American health care system remains the only system among all the major industrialized nations on earth that doesn’t ensure access for all its citizens. The American health care system is fundamentally a business enterprise. This sector has captured approximately $3.5 trillion of the American economy annually. Stunningly, this represents over 1/6 (17%) of the gross domestic product.

The US is number one in money spent on health care by a large margin. In fact, the U.S. spends more on people aged over 65 than any other country spends on its entire population. The business of medicine in America is business first. It is largely expected that good health care outcomes will result from good business. Health care is viewed as a commodity in the same way that good cars, computers and smartphones are. Does this work? The outcomes say otherwise. According to the World Health Organization, the U.S. health care system was ranked #38 in the last WHO ranking based on standard health outcomes produced.

The Affect of the Affordable Care Act on Equal Access to Health Care

Despite any perceived and actual flaws in the ACA, one unassailable fact exists. Approximately 20 million previously uninsured Americans obtained it through the passage of the Affordable Care Act. The ACA targets its assistance to the poor and near-poor who are least likely to have health care coverage. The ACA will provide Medicaid coverage to those with incomes up to 133 percent of the poverty level (approximately $16,000). Unfortunately, this isn’t true in states opting out of the Medicaid expansion. People earning between the poverty level and four times that amount are eligible for tax credits for private health insurance.

Access to health care is the beginning of the process by which health care disparities can be erased. As long as failure to have equal access exists to the extent that it does, the types of disparities in life expectancy, disease rates and disease survival will remain predictably dismal for certain populations. As long as total our population is unhealthy in general, and pockets of our population are more disproportionately unhealthy, we will remain less productive and cohesive than we could be. Predictably, these facts will perpetrate a host of additional problems within our society.


Finally and furthermore, one question still begs to be asked. Why does the US choose to remain the only major industrialized nation in the world that fails to provide universal health care for its citizenry? What part of life, liberty and the pursuit of happiness involves doing so without health? How is that Justice?

Happy MLK Day. Remember the Dream, but also remember how that plays out in our lives.

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Ask your SMA expert consultant any questions you may have on this topic. Also, take the #72HoursChallenge, and join the community. Additionally, as a thank you, we’re offering you a complimentary 30-day membership at www.72hourslife.com. Just use the code #NoChaser, and yes, it’s ok if you share!

Order your copy of Dr. Sterling’s books There are 72 Hours in a Day: Using Efficiency to Better Enjoy Every Part of Your Life and The 72 Hours in a Day Workbook: The Journey to The 72 Hours Life in 72 Days at Amazon or at www.jeffreysterlingbooks.com. Another free benefit to our readers is introductory pricing with multiple orders and bundles!

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Straight, No Chaser In The News: President Trump Eliminates Low-Income Subsidies for Obamacare

President Trump just removed federal funding for Affordable Care Act (aka ACA, Obamacare) subsidies. Here are five quick answers to questions you should have about this action – and a resource.
1.Exactly what happened – I thought Congress approved the ACA. How can he do this?
The funding in question isn’t the global pot of money that sustains the Affordable Care Act, but supplemental funding under the control of the Executive Branch mean to subsidize (i.e. reimburse) insurance companies for maintaining relatively low rates for lower-income ACA enrollees.
2. Does this mean the ACA is no longer funded?
Actually no. Nothing changes immediately, but you should expect the insurance companies to react to the loss of these subsidies and pretty dramatically raise rates.

3. What will do to my insurance under the ACA?
Over time, expect your rates to skyrocket by an amount proportionate to the revenue lost by the insurance companies. Alternatively and/or additionally, with this and the other assaults on the ACA by President Trump, you can anticipate many insurers leaving the ACA exchanges due to the uncertainty these actions bring to the system. Of course, if this happens, you’ ll disproportionately affected if you’re in the group for whom the subsidies was intended (i.e. lower and middle class) and/or live in the South.

4. Practically speaking, what does this mean (what’s the bottom line on the bottom dollar)?
As noted, almost 60% of marketplace costs are subsidized. Without Congressional action, that could be the amount of rise in your costs if you currently qualify for a subsidy.
5. What can I do to secure my insurance under the ACA?
If you have insurance under the ACA, the enrollment period is now. In a separate action, 90% of the advertising budget for enrollment was eliminated, so you may not know that the ACA enrollment period has been shortened to between November 1 and December 15, 2017. Check at www.healthcare.gov for additional information.
To whom do I complain? Here’s a link for a previous post that lists the local numbers to your Congressmen: https://jeffreysterlingmd.com/2017/09/25/92382/. If you’re going to be affected by this or if you just care, the next step is to have Congress write these subsidies into law instead of them being part of executive actions that get added or eliminated based on which party is in office.
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Feel free to ask your SMA expert consultant any questions you may have on this topic.
Take the #72HoursChallenge, and join the community. As a thank you for being a valued subscriber to Straight, No Chaser, we’d like to offer you a complimentary 30-day membership at www.72hourslife.com. Just use the code #NoChaser, and yes, it’s ok if you share!
Order your copy of Dr. Sterling’s new books There are 72 Hours in a Day: Using Efficiency to Better Enjoy Every Part of Your Life and The 72 Hours in a Day Workbook: The Journey to The 72 Hours Life in 72 Days at Amazon or at www.72hourslife.com. Receive introductory pricing with orders!
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK offers. Please share our page with your friends on WordPress, like us on Facebook SterlingMedicalAdvice.com and follow us on Twitter at @asksterlingmd.
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Straight, No Chaser in the News: Evaluating the Next Version of Trumpcare – The Graham-Cassidy Bill (Includes Numbers for Your Senator)


The newest effort to repeal and replace the Affordable Care Act (aka Obamacare, ACA) is called the Graham-Cassidy Bill. Although the actual legislation has been clouded in secrecy, there are a few fundamentals that can be shared, and we’ll present them in Q&A format. Be reminded that this reform is meant to impact approximately 1/6th of the United States economy. We’ve done our best to prevent facts Straight, No Chaser style, so consider points that seem slanted self-evident truths and evaluate your reaction to them.

I. What’s a block grant? Let’s address both the facts and the spin. Block grants are a means for the federal government to cap expenses by taking a fixed amount of funds (typically what’s currently or historically being spent) and offering those same funds to individual states for their management. This isn’t a new idea. Republicans have been pushing block grants for Medicaid since the Reagan administration (1981). Block grants were notably used in converting welfare (Aid to Families with Dependent Children) away from an entitlement program in 1996. The spin (and the danger) is states would be allowed to manage those funds as they saw fit, which allows for either greater or lesser health protections, as well as innovation and restrictions. Simply put, states would be empowered to decide what services are offered and who would qualify for those services.

2. What would happen to Medicaid? In the block grant scenario, the amount would be capped with annual adjustments to account for inflation, but those amounts would not keep pace with the rate of medical inflation. In other words, states would eventually have less money with which to work. Furthermore, the proposal explicitly ends coverage for childless adults and ends the Medicaid expansion that occurred under Obamacare and currently covers 15 million adults. As such, there will be a massive redistribution away from states who opted into the ACA Medicaid expansion toward those that did not. Although the Congressional Budget Office hasn’t yet had time to score the Graham-Cassidy bill, in the past, it has opined that block grant proposals could cut Medicaid spending by as much as a third over the next decade. That’s not all. Most notoriously, the block grant would end after 2026. That’s right, in ten years the federal government would have to renew the grant, or states would need to replace every last federal dollar or roll back coverage even more. In other words, all funds currently assigned to Medicaid and the ACA would no longer be spent by the federal government in ten years under the currently proposed bill. Whether or not you believe in reducing costs, you should be quite concerned about the lack of market stability that represents, much less what’s going to happen to health care in 10 years. A conservative estimate is tens of millions of Americans will lose healthcare under any scenario of Graham-Cassidy.

3. How are preexisting conditions affected? Here’s the facts and the spin. Based on the best information available, states would be required to “offer” services to those with preexisting conditions. However, remember that services are actually provided by insurance companies. This bill neither addresses pricing nor mandates affordability to those covered. Thus, a health service could be offered, but it is probable that the price of coverage will become so high for the high-risk patient and those with preexisting conditions that they’ll either elect to or not be able to pay the cost. The nuances here allow competing interests to claim both that pre-existing conditions are or are not going to be covered.

4. Is this supported by the medical and public health communities? How about the public? Every conceivable apolitical sector, from hospitals, insurance companies, health organizations and the public are speaking out against this proposal. On Saturday, a joint press release was signed by multiple prominent medical organizations and insurance companies, united in opposition to the bill. Signing healthcare entities included the following: American Medical Association, American Academy of Family Physicians, Federation of American Hospitals, American Hospital Association, American Health Insurance Plans and the Blue Cross Blue Shield Association. Here is a quote from the press release: “While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all… The Graham-Cassidy-Heller-Johnson bill does not move us closer to that goal. The Senate should reject it.” Only 24 percent of Americans support Graham-Cassidy, according to a new poll released Thursday by Public Policy Polling. Meanwhile, the public supports retaining the Affordable Care Act over replacing it with the proposed Graham-Cassidy bill by 56-33 percent in a new ABC News/Washington Post poll.

5. What’s going on with Obamacare (Affordable Care Act/ACA) these days? It actually is very much intact, although multiple executive orders have been enacted to weaken it (that will further the appearance and reality that it is flawed). The Trump administration has reduced advertising funds by 90% to announce enrollment, but you should know enrollment for 2018 starts November 1 and ends December 15.

6. Are there any women’s health concerns? It is implicit in the effort to rollback delivery of healthcare to the states that politics will play a role in multiple issues, including those of women’s health. It is explicitly of note that the Graham-Cassidy proposal eliminates federal funding to Planned Parenthood for one year.

7. How can I express my concern? What follows is an exhaustive list of contact numbers for your Senators. Media reporting suggests the number of calls hasn’t been close to that of previous efforts to repeal the ACA, so if you have a voice to share, you have until week’s end (Friday) to be heard.

StateSenatorOffice LocationPhone Number
AlabamaStrange, LutherBirmingham(205) 731-1500
AlabamaStrange, LutherHuntsville(256) 533-0979
AlabamaStrange, LutherMobile(251) 414-3083
AlabamaStrange, LutherMontgomery(334) 230-0698
AlabamaStrange, LutherWashington, D.C.(202) 224-4124
AlabamaStrange, LutherWiregrass(334) 792-4924
AlabamaShelby, RichardBirmingham(205) 731-1384
AlabamaShelby, RichardHuntsville(256) 772-0460
AlabamaShelby, RichardMobile(251) 694-4164
AlabamaShelby, RichardMontgomery(334) 223-7303
AlabamaShelby, RichardTuscaloosa(205) 759-5047
AlabamaShelby, RichardWashington, D.C.(202) 224-5744
AlaskaMurkowski, LisaAnchorage(907) 271-3735
AlaskaMurkowski, LisaFairbanks(907) 456-0233
AlaskaMurkowski, LisaJuneau(907) 586-7277
AlaskaMurkowski, LisaKenai(907) 283-5808
AlaskaMurkowski, LisaKetchikan(907) 225-6880
AlaskaMurkowski, LisaMat-Su Valley(907) 376-7665
AlaskaMurkowski, LisaWashington, D.C.(202) 224-6665
AlaskaSullivan, DanAnchorage(907) 271-5915
AlaskaSullivan, DanFairbanks(907) 456-0261
AlaskaSullivan, DanJuneau(907) 586-7277
AlaskaSullivan, DanKenai(907) 283-4000
AlaskaSullivan, DanKetchikan(907) 225-6880
AlaskaSullivan, DanMat-Su Valley(907) 357-9956
AlaskaSullivan, DanWashington, D.C.(202) 224-3004
ArizonaFlake, JeffPhoenix(602) 840-1891
ArizonaFlake, JeffTucson(520) 575-8633
ArizonaFlake, JeffWashington, D.C.(202) 224-4521
ArizonaMcCain, JohnPhoenix(602) 952-2410
ArizonaMcCain, JohnPrescott(928) 445-0833
ArizonaMcCain, JohnTucson(520) 670-6334
ArizonaMcCain, JohnWashington, D.C.(202) 224-2235
ArkansasBoozman, JohnEl Dorado(870) 863-4641
ArkansasBoozman, JohnFort Smith(479) 573-0189
ArkansasBoozman, JohnJonesboro(870) 268-6925
ArkansasBoozman, JohnLittle Rock(501) 372-7153
ArkansasBoozman, JohnLowell(479) 725-0400
ArkansasBoozman, JohnMountain Home(870) 424-0129
ArkansasBoozman, JohnStuttgart(870) 672-6941
ArkansasBoozman, JohnWashington, D.C.(202) 224-4843
ArkansasCotton, TomEl Dorado(870) 864-8582
ArkansasCotton, TomJonesboro(870) 933-6223
ArkansasCotton, TomLittle Rock(501) 223-9081
ArkansasCotton, TomSpringdale(479) 751-0879
ArkansasCotton, TomWashington, D.C.(202) 224-2353
CaliforniaFeinstein, DianneFresno(559) 485-7430
CaliforniaFeinstein, DianneLos Angeles(310) 914-7300
CaliforniaFeinstein, DianneSan Diego(619) 231-9712
CaliforniaFeinstein, DianneSan Francisco(415) 393-0707
CaliforniaFeinstein, DianneWashington, D.C.(202) 224-3841
CaliforniaHarris, KamalaFresno(916) 448-2787
CaliforniaHarris, KamalaLos Angeles(213) 894-5000
CaliforniaHarris, KamalaSacramento(916) 448-2787
CaliforniaHarris, KamalaSan Diego(619) 239-3884
CaliforniaHarris, KamalaSan Francisco(213) 894-5000
CaliforniaHarris, KamalaWashington, D.C.(202) 224-3553
ColoradoBennet, MichaelArkansas Valley(719) 542-7550
ColoradoBennet, MichaelDenver Metro(303) 455-7600
ColoradoBennet, MichaelFour Corners(970) 259-1710
ColoradoBennet, MichaelNorthern Colorado(970) 224-2200
ColoradoBennet, MichaelNorthwest/I-70W(970) 241-6631
ColoradoBennet, MichaelPikes Peak(719) 328-1100
ColoradoBennet, MichaelSan Luis Valley(719) 587-0096
ColoradoBennet, MichaelWashington, D.C.(202) 224-5852
ColoradoGardner, CoryColorado Springs(719) 632-6706
ColoradoGardner, CoryDenver(303) 391-5777
ColoradoGardner, CoryFort Collins(970) 484-3502
ColoradoGardner, CoryGrand Junction(970) 245-9553
ColoradoGardner, CoryGreeley(970) 352-5546
ColoradoGardner, CoryPueblo(719) 543-1324
ColoradoGardner, CoryWashington, D.C.(202) 224-5941
ColoradoGardner, CoryYuma(970) 848-3095
ConnecticutBlumenthal, RichardBridgeport(203) 330-0598
ConnecticutBlumenthal, RichardHartford(860) 258-6940
ConnecticutBlumenthal, RichardWashington, D.C.(202) 224-2823
ConnecticutMurphy, ChrisHartford(860) 549-8463
ConnecticutMurphy, ChrisWashington, D.C.(202) 224-4041
DelawareCarper, TomDover(302) 674-3308
DelawareCarper, TomGeorgetown(302) 856-7690
DelawareCarper, TomWashington, D.C.(202) 224-2441
DelawareCarper, TomWilmington(302) 573-6291
DelawareCoons, ChrisDover(302) 736-5601
DelawareCoons, ChrisWashington, D.C.(202) 224-5042
DelawareCoons, ChrisWilmington(302) 573-6345
FloridaNelson, BillBroward(954) 693-4851
FloridaNelson, BillFort Myers(239) 334-7760
FloridaNelson, BillJacksonville(904) 346-4500
FloridaNelson, BillMiami-Dade(305) 536-5999
FloridaNelson, BillOrlando(407) 872-7161
FloridaNelson, BillTallahassee(850) 942-8415
FloridaNelson, BillTampa(813) 225-7040
FloridaNelson, BillWashington, D.C.(202) 224-5274
FloridaNelson, BillWest Palm Beach(561) 514-0189
FloridaRubio, MarcoJacksonville(904) 398-8586
FloridaRubio, MarcoMiami(305) 418-8553
FloridaRubio, MarcoNaples(239) 213-1521
FloridaRubio, MarcoOrlando(407) 254-2573
FloridaRubio, MarcoPalm Beach(561) 775-3360
FloridaRubio, MarcoPensacola(850) 433-2603
FloridaRubio, MarcoTallahassee(850) 599-9100
FloridaRubio, MarcoTampa(813) 287-5035
FloridaRubio, MarcoWashington, D.C.(202) 224-3041
GeorgiaIsakson, JohnnyAtlanta(770) 661-0999
GeorgiaIsakson, JohnnyWashington, D.C.(202) 224-3643
GeorgiaPerdue, DavidAtlanta(404) 865-0087
GeorgiaPerdue, DavidWashington, D.C.(202) 224-3521
HawaiiHirono, MazieHawaii(808) 522-8970
HawaiiHirono, MazieWashington, D.C.(202) 224-6361
HawaiiSchatz, BrianHonolulu(808) 523-2061
HawaiiSchatz, BrianWashington, D.C.(202) 224-3934
IdahoCrapo, MikeEastern Idaho, North(208) 522-9779
IdahoCrapo, MikeEastern Idaho, South(208) 236-6775
IdahoCrapo, MikeIdaho State(208) 334-1776
IdahoCrapo, MikeNorth Idaho(208) 664-5490
IdahoCrapo, MikeNorth-Central Idaho(208) 743-1492
IdahoCrapo, MikeSouth-Central Idaho(208) 734-2515
IdahoCrapo, MikeWashington, D.C.(202) 224-6142
IdahoRisch, JimBoise(208) 342-7985
IdahoRisch, JimCoeur D’Alene(208) 667-6130
IdahoRisch, JimIdaho Falls(208) 523-5541
IdahoRisch, JimLewiston(208) 743-0792
IdahoRisch, JimPocatello(208) 236-6817
IdahoRisch, JimTwin Falls(208) 734-6780
IdahoRisch, JimWashington, D.C.(202) 224-2752
IllinoisDuckworth, TammyChicago(312) 886-3506
IllinoisDuckworth, TammyWashington, D.C.(202) 224-2854
IllinoisDurbin, RichardCarbondale(618) 351-1122
IllinoisDurbin, RichardChicago(312) 353-4952
IllinoisDurbin, RichardRock Island(309) 786-5173
IllinoisDurbin, RichardSpringfield(217) 492-4062
IllinoisDurbin, RichardWashington, D.C.(202) 224-2152
IndianaDonnelly, JoeEvansville(812) 425-5813
IndianaDonnelly, JoeFort Wayne(260) 420-4955
IndianaDonnelly, JoeHammond(219) 852-0089
IndianaDonnelly, JoeIndianapolis(317) 226-5555
IndianaDonnelly, JoeJeffersonville(812) 284-2027
IndianaDonnelly, JoeSouth Bend(574) 288-2780
IndianaDonnelly, JoeWashington, D.C.(202) 224-4814
IndianaYoung, ToddEvansville
IndianaYoung, ToddFort Wayne
IndianaYoung, ToddIndianapolis(317) 226-6700
IndianaYoung, ToddNew Albany(812) 542-4820
IndianaYoung, ToddWashington, D.C.(202) 224-5623
IowaErnst, JoniCedar Rapids(319) 365-4504
IowaErnst, JoniCouncil Bluffs(712) 352-1167
IowaErnst, JoniDavenport(563) 322-0677
IowaErnst, JoniDes Moines(515) 284-4574
IowaErnst, JoniSioux City(712) 252-1550
IowaErnst, JoniWashington, D.C.(202) 224-3254
IowaGrassley, ChuckCedar Rapids(319) 363-6832
IowaGrassley, ChuckCouncil Bluffs(712) 322-7103
IowaGrassley, ChuckDavenport(563) 322-4331
IowaGrassley, ChuckDes Moines(515) 288-1145
IowaGrassley, ChuckSioux City(712) 233-1860
IowaGrassley, ChuckWashington, D.C.(202) 224-3744
IowaGrassley, ChuckWaterloo(319) 232-6657
KansasMoran, JerryHays(785) 628-6401
KansasMoran, JerryManhattan(785) 539-8973
KansasMoran, JerryOlathe(913) 393-0711
KansasMoran, JerryPittsburg(620) 232-2286
KansasMoran, JerryWashington, D.C.(202) 224-6521
KansasMoran, JerryWichita(316) 631-1410
KansasRoberts, PatDodge City(620) 227-2244
KansasRoberts, PatOverland Park(913) 451-9343
KansasRoberts, PatTopeka(785) 295-2745
KansasRoberts, PatWashington, D.C.(202) 224-4774
KansasRoberts, PatWichita(316) 263-0416
KentuckyMcConnell, MitchBowling Green(270) 781-1673
KentuckyMcConnell, MitchFt. Wright(859) 578-0188
KentuckyMcConnell, MitchLexington(859) 224-8286
KentuckyMcConnell, MitchLondon(606) 864-2026
KentuckyMcConnell, MitchLouisville(502) 582-6304
KentuckyMcConnell, MitchPaducah(270) 442-4554
KentuckyMcConnell, MitchWashington, D.C.(202) 224-2541
KentuckyPaul, RandBowling Green(270) 782-8303
KentuckyPaul, RandCrescent Springs(859) 426-0165
KentuckyPaul, RandHopkinsville(270) 885-1212
KentuckyPaul, RandLexington(859) 219-2239
KentuckyPaul, RandLouisville(502) 582-5341
KentuckyPaul, RandOwensboro(270) 689-9085
KentuckyPaul, RandWashington, D.C.(202) 224-4343
LousianaCassidy, BillAlexandria(318) 448-7176
LousianaCassidy, BillBaton Rouge(225) 929-7711
LousianaCassidy, BillLafayette(337) 261-1400
LousianaCassidy, BillLake Charles(337) 493-5398
LousianaCassidy, BillMetairie(504) 838-0130
LousianaCassidy, BillMonroe(318) 324-2111
LousianaCassidy, BillShreveport(318) 798-3215
LousianaCassidy, BillWashington, D.C.(202) 224-5824
LousianaKennedy, JohnWashington, D.C.(202) 224-4623
MaineCollins, SusanAugusta(207) 622-8414
MaineCollins, SusanBangor(207) 945-0417
MaineCollins, SusanBiddeford(207) 283-1101
MaineCollins, SusanCaribou(207) 493-7873
MaineCollins, SusanLewiston(207) 784-6969
MaineCollins, SusanPortland(207) 780-3575
MaineCollins, SusanWashington, D.C.(202) 224-2523
MaineKing, AngusAugusta(207) 622-8292
MaineKing, AngusBangor(207) 945-8000
MaineKing, AngusPresque Isle(207) 764-5124
MaineKing, AngusScarborough(207) 883-1588
MaineKing, AngusWashington, D.C.(202) 224-5344
MarylandCardin, BenBaltimore(410) 962-4436
MarylandCardin, BenBowie(301) 860-0414
MarylandCardin, BenCumberland(301) 777-2957
MarylandCardin, BenRockville(301) 762-2974
MarylandCardin, BenSalisbury(410) 546-4250
MarylandCardin, BenSouthern Maryland(202) 870-1164
MarylandCardin, BenWashington, D.C.(202) 224-4524
MarylandVan Hollen, ChrisWashington, D.C.(202) 224-4654
MassachusettsMarkey, EdBoston(617) 565-8519
MassachusettsMarkey, EdFall River(508) 677-0523
MassachusettsMarkey, EdSpringfield(413) 785-4610
MassachusettsMarkey, EdWashington, D.C.(202) 224-2742
MassachusettsWarren, ElizabethBoston(617) 565-3170
MassachusettsWarren, ElizabethSpringfield(413) 788-2690
MassachusettsWarren, ElizabethWashington, D.C.(202) 224-4543
MichiganPeters, GaryDetroit(313) 226-6020
MichiganPeters, GaryGrand Rapids(616) 233-9150
MichiganPeters, GaryLansing(517) 377-1508
MichiganPeters, GaryMarquette(906) 226-4554
MichiganPeters, GaryRochester(248) 608-8040
MichiganPeters, GarySaginaw(989) 754-0112
MichiganPeters, GaryTraverse City(231) 947-7773
MichiganPeters, GaryWashington, D.C.(202) 224-6221
MichiganStabenow, DebbieFlint/Saginaw Bay(810) 720-4172
MichiganStabenow, DebbieMid-Michigan(517) 203-1760
MichiganStabenow, DebbieNorthern Michigan(231) 929-1031
MichiganStabenow, DebbieSoutheast Michigan(313) 961-4330
MichiganStabenow, DebbieUpper Peninsula(906) 228-8756
MichiganStabenow, DebbieWashington, D.C.(202) 224-4822
MichiganStabenow, DebbieWest Michigan(616) 975-0052
MinnesotaFranken, AlDuluth(218) 722-2390
MinnesotaFranken, AlMoorhead(218) 284-8721
MinnesotaFranken, AlRochester(507) 288-2003
MinnesotaFranken, AlSaint Paul(651) 221-1016
MinnesotaFranken, AlWashington, D.C.(202) 224-5641
MinnesotaKlobuchar, AmyMetro(612) 727-5220
MinnesotaKlobuchar, AmyNortheastern(218) 741-9690
MinnesotaKlobuchar, AmyNorthwestern & Central(218) 287-2219
MinnesotaKlobuchar, AmySouthern(507) 288-5321
MinnesotaKlobuchar, AmyWashington, D.C.(202) 224-3244
MississippiCochran, ThadGulf Coast(228) 867-9710
MississippiCochran, ThadJackson(601) 965-4459
MississippiCochran, ThadOxford(662) 236-1018
MississippiCochran, ThadWashington, D.C.(202) 224-5054
MississippiWicker, RogerGulfport(228) 871-7017
MississippiWicker, RogerHernando(662) 429-1002
MississippiWicker, RogerJackson(601) 965-4644
MississippiWicker, RogerTupelo(662) 844-5010
MississippiWicker, RogerWashington, D.C.(202) 224-6253
MissouriBlunt, RoyCape Girardeau(573) 334-7044
MissouriBlunt, RoyColumbia(573) 442-8151
MissouriBlunt, RoyKansas City(816) 471-7141
MissouriBlunt, RoySpringfield(417) 877-7814
MissouriBlunt, RoySt. Louis/Clayton(314) 725-4484
MissouriBlunt, RoyWashington, D.C.(202) 224-5721
MissouriMcCaskill, ClaireCape Girardeau(573) 651-0964
MissouriMcCaskill, ClaireColumbia(573) 442-7130
MissouriMcCaskill, ClaireKansas City(816) 421-1639
MissouriMcCaskill, ClaireSpringfield(417) 868-8745
MissouriMcCaskill, ClaireSt. Louis(314) 367-1364
MissouriMcCaskill, ClaireWashington, D.C.(202) 224-6154
MontanaDaines, SteveBillings(406) 245-6822
MontanaDaines, SteveBozeman(406) 587-3446
MontanaDaines, SteveGreat Falls(406) 453-0148
MontanaDaines, SteveHardin(406) 665-4126
MontanaDaines, SteveHelena(406) 443-3189
MontanaDaines, SteveKalispell(406) 257-3765
MontanaDaines, SteveMissoula(406) 549-8198
MontanaDaines, SteveSidney(406) 482-9010
MontanaDaines, SteveWashington, D.C.(202) 224-2651
MontanaTester, JonBillings(406) 252-0550
MontanaTester, JonBozeman(406) 586-4450
MontanaTester, JonButte(406) 723-3277
MontanaTester, JonGlendive(406) 365-2391
MontanaTester, JonGreat Falls(406) 452-9585
MontanaTester, JonHelena(406) 449-5401
MontanaTester, JonKalispell(406) 257-3360
MontanaTester, JonMissoula(406) 728-3003
MontanaTester, JonWashington, D.C.(202) 224-2644
NebraskaFischer, DebKearney(308) 234-2361
NebraskaFischer, DebLincoln(402) 441-4600
NebraskaFischer, DebNorfolk(402) 200-8816
NebraskaFischer, DebOmaha(402) 391-3411
NebraskaFischer, DebScottsbluff(308) 630-2329
NebraskaFischer, DebWashington, D.C.(202) 224-6551
NebraskaSasse, BenKearney(308) 233-3677
NebraskaSasse, BenLincoln(402) 476-1400
NebraskaSasse, BenOmaha(402) 550-8040
NebraskaSasse, BenScottsbluff(308) 632-6032
NebraskaSasse, BenWashington, D.C.(202) 224-4224
NevadaCortez Masto, CatherineLas Vegas(702) 388-5020
NevadaCortez Masto, CatherineReno(775) 686-5750
NevadaCortez Masto, CatherineWashington, D.C.(202) 224-3542
NevadaHeller, DeanLas Vegas(702) 388-6605
NevadaHeller, DeanReno(775) 686-5770
NevadaHeller, DeanWashington, D.C.(202) 224-6244
New HampshireHassan, MaggieManchester(603) 622-2204
New HampshireHassan, MaggieWashington, D.C.(202) 224-3324
New HampshireShaheen, JeanneBerlin(603) 752-6300
New HampshireShaheen, JeanneClaremont(603) 542-4872
New HampshireShaheen, JeanneDover(603) 750-3004
New HampshireShaheen, JeanneKeene(603) 358-6604
New HampshireShaheen, JeanneManchester(603) 647-7500
New HampshireShaheen, JeanneNashua(603) 883-0196
New HampshireShaheen, JeanneWashington, D.C.(202) 224-2841
New JerseyBooker, CoryCamden(856) 338-8922
New JerseyBooker, CoryNewark(973) 639-8700
New JerseyBooker, CoryWashington, D.C.(202) 224-3224
New JerseyMenendez, BobBarrington(856) 757-5353
New JerseyMenendez, BobNewark(973) 645-3030
New JerseyMenendez, BobWashington, D.C.(202) 224-4744
New MexicoHeinrich, MartinAlbuquerque(505) 346-6601
New MexicoHeinrich, MartinFarmington(505) 325-5030
New MexicoHeinrich, MartinLas Cruces(575) 523-6561
New MexicoHeinrich, MartinRoswell(575) 622-7113
New MexicoHeinrich, MartinSanta Fe(505) 988-6647
New MexicoHeinrich, MartinWashington, D.C.(202) 224-5521
New MexicoUdall, TomAlbuquerque(505) 346-6791
New MexicoUdall, TomCarlsbad(575) 234-0366
New MexicoUdall, TomEastside(575) 356-6811
New MexicoUdall, TomLas Cruces(575) 526-5475
New MexicoUdall, TomSanta Fe(505) 988-6511
New MexicoUdall, TomWashington, D.C.(202) 224-6621
New YorkGillibrand, KirstenAlbany(518) 431-0120
New YorkGillibrand, KirstenBuffalo(716) 854-9725
New YorkGillibrand, KirstenHudson Valley(845) 875-4585
New YorkGillibrand, KirstenLong Island(631) 249-2825
New YorkGillibrand, KirstenNew York City(212) 688-6262
New YorkGillibrand, KirstenNorth Country(315) 376-6118
New YorkGillibrand, KirstenRochester(585) 263-6250
New YorkGillibrand, KirstenSyracuse(315) 448-0470
New YorkGillibrand, KirstenWashington, D.C.(202) 224-4451
New YorkSchumer, ChuckAlbany(518) 431-4070
New YorkSchumer, ChuckBinghamton(607) 772-6792
New YorkSchumer, ChuckBuffalo(716) 846-4111
New YorkSchumer, ChuckMelville(631) 753-0978
New YorkSchumer, ChuckNew York City(212) 486-4430
New YorkSchumer, ChuckPeekskill(914) 734-1532
New YorkSchumer, ChuckRochester(585) 263-5866
New YorkSchumer, ChuckSyracuse(315) 423-5471
New YorkSchumer, ChuckWashington, D.C.(202) 224-6542
North CarolinaBurr, RichardAsheville(828) 350-2437
North CarolinaBurr, RichardGastonia(704) 833-0854
North CarolinaBurr, RichardRocky Mount(252) 977-9522
North CarolinaBurr, RichardWashington, D.C.(202) 224-3154
North CarolinaBurr, RichardWilmington(910) 251-1058
North CarolinaBurr, RichardWinston-Salem(336) 631-5125
North CarolinaTillis, ThomCharlotte(704) 509-9087
North CarolinaTillis, ThomGreenville(252) 329-0371
North CarolinaTillis, ThomHendersonville(828) 693-8750
North CarolinaTillis, ThomHigh Point(336) 885-0685
North CarolinaTillis, ThomRaleigh(919) 856-4630
North CarolinaTillis, ThomWashington, D.C.(202) 224-6342
North DakotaHeitkamp, HeidiBismarck(701) 258-4648
North DakotaHeitkamp, HeidiDickinson(701) 225-0974
North DakotaHeitkamp, HeidiFargo(701) 232-8030
North DakotaHeitkamp, HeidiGrand Forks(701) 775-9601
North DakotaHeitkamp, HeidiMinot(701) 852-0703
North DakotaHeitkamp, HeidiWashington, D.C.(202) 224-2043
North DakotaHoeven, JohnBismarck(701) 250-4618
North DakotaHoeven, JohnFargo(701) 239-5389
North DakotaHoeven, JohnGrand Forks(701) 746-8972
North DakotaHoeven, JohnMinot(701) 838-1361
North DakotaHoeven, JohnWashington, D.C.(202) 224-2551
North DakotaHoeven, JohnWestern North Dakota(701) 580-4535
OhioBrown, SherrodCincinnati(513) 684-1021
OhioBrown, SherrodCleveland(216) 522-7272
OhioBrown, SherrodColumbus(614) 469-2083
OhioBrown, SherrodLorain(440) 242-4100
OhioBrown, SherrodWashington, D.C.(202) 224-2315
OhioPortman, RobCincinnati(513) 684-3265
OhioPortman, RobCleveland(216) 522-7095
OhioPortman, RobColumbus(614) 469-6774
OhioPortman, RobToledo(419) 259-3895
OhioPortman, RobWashington, D.C.(202) 224-3353
OklahomaInhofe, JimEnid(580) 234-5105
OklahomaInhofe, JimMcAlester(918) 426-0933
OklahomaInhofe, JimOklahoma City(405) 608-4381
OklahomaInhofe, JimTulsa(918) 748-5111
OklahomaInhofe, JimWashington, D.C.(202) 224-4721
OklahomaLankford, JamesOklahoma City(405) 231-4941
OklahomaLankford, JamesTulsa(918) 581-7651
OklahomaLankford, JamesWashington, D.C.(202) 224-5754
OregonMerkley, JeffBend(541) 318-1298
OregonMerkley, JeffEugene(541) 465-6750
OregonMerkley, JeffMedford(541) 608-9102
OregonMerkley, JeffPendleton(541) 278-1129
OregonMerkley, JeffPortland(503) 326-3386
OregonMerkley, JeffSalem(503) 362-8102
OregonMerkley, JeffWashington, D.C.(202) 224-3753
OregonWyden, RonBend(541) 330-9142
OregonWyden, RonEugene(541) 431-0229
OregonWyden, RonLa Grande(541) 962-7691
OregonWyden, RonMedford(541) 858-5122
OregonWyden, RonPortland(503) 326-7525
OregonWyden, RonSalem(503) 589-4555
OregonWyden, RonWashington, D.C.(202) 224-5244
PennsylvaniaCasey, BobCentral Pa(814) 357-0314
PennsylvaniaCasey, BobErie(814) 874-5080
PennsylvaniaCasey, BobHarrisburg(717) 231-7540
PennsylvaniaCasey, BobLehigh Valley(610) 782-9470
PennsylvaniaCasey, BobNortheastern(570) 941-0930
PennsylvaniaCasey, BobPhiladelphia(215) 405-9660
PennsylvaniaCasey, BobPittsburgh(412) 803-7370
PennsylvaniaCasey, BobWashington, D.C.(202) 224-6324
PennsylvaniaToomey, PatAllentown/Lehigh Valley(610) 434-1444
PennsylvaniaToomey, PatErie(814) 453-3010
PennsylvaniaToomey, PatHarrisburg(717) 782-3951
PennsylvaniaToomey, PatJohnstown(814) 266-5970
PennsylvaniaToomey, PatPhiladelphia(215) 241-1090
PennsylvaniaToomey, PatPittsburgh(412) 803-3501
PennsylvaniaToomey, PatScranton(570) 941-3540
PennsylvaniaToomey, PatWashington, D.C.(202) 224-4254
Rhode IslandReed, JackCranston(401) 943-3100
Rhode IslandReed, JackProvidence(401) 528-5200
Rhode IslandReed, JackWashington, D.C.(202) 224-4642
Rhode IslandWhitehouse, SheldonProvidence(401) 453-5294
Rhode IslandWhitehouse, SheldonWashington, D.C.(202) 224-2921
South CarolinaGraham, LindseyGolden Corner(864) 646-4090
South CarolinaGraham, LindseyLowcountry(843) 849-3887
South CarolinaGraham, LindseyMidlands(803) 933-0112
South CarolinaGraham, LindseyPee Dee(843) 669-1505
South CarolinaGraham, LindseyPiedmont(803) 366-2828
South CarolinaGraham, LindseyUpstate(864) 250-1417
South CarolinaGraham, LindseyWashington, D.C.(202) 224-5972
South CarolinaScott, TimLowcountry(843) 727-4525
South CarolinaScott, TimMidlands(803) 771-6112
South CarolinaScott, TimUpstate(864) 233-5366
South CarolinaScott, TimWashington, D.C.(202) 224-6121
South DakotaRounds, MikeAberdeen(605) 225-0366
South DakotaRounds, MikePierre(605) 224-1450
South DakotaRounds, MikeRapid City(605) 343-5035
South DakotaRounds, MikeSioux Falls(605) 336-0486
South DakotaRounds, MikeWashington, D.C.(202) 224-5842
South DakotaThune, JohnAberdeen(605) 225-8823
South DakotaThune, JohnRapid City(605) 348-7551
South DakotaThune, JohnSioux Falls(605) 334-9596
South DakotaThune, JohnWashington, D.C.(202) 224-2321
TennesseeAlexander, LamarChattanooga(423) 752-5337
TennesseeAlexander, LamarJackson(731) 664-0289
TennesseeAlexander, LamarKnoxville(865) 545-4253
TennesseeAlexander, LamarMemphis(901) 544-4224
TennesseeAlexander, LamarNashville(615) 736-5129
TennesseeAlexander, LamarTri-Cities(423) 325-6240
TennesseeAlexander, LamarWashington, D.C.(202) 224-4944
TennesseeCorker, BobChattanooga(423) 756-2757
TennesseeCorker, BobJackson(731) 664-2294
TennesseeCorker, BobKnoxville(865) 637-4180
TennesseeCorker, BobMemphis(901) 683-1910
TennesseeCorker, BobNashville(615) 279-8125
TennesseeCorker, BobTri-Cities(423) 753-2263
TennesseeCorker, BobWashington, D.C.(202) 224-3344
TexasCornyn, JohnCentral Texas(512) 469-6034
TexasCornyn, JohnEast Texas(903) 593-0902
TexasCornyn, JohnNorth Texas(972) 239-1310
TexasCornyn, JohnSouth Central Texas(210) 224-7485
TexasCornyn, JohnSouth Texas(956) 423-0162
TexasCornyn, JohnSoutheast Texas(713) 572-3337
TexasCornyn, JohnWashington, D.C.(202) 224-2934
TexasCornyn, JohnWest Texas(806) 472-7533
TexasCruz, TedCentral Texas(512) 916-5834
TexasCruz, TedEast Texas(903) 593-5130
TexasCruz, TedNorth Texas(214) 599-8749
TexasCruz, TedSouth Texas(956) 686-7339
TexasCruz, TedSouth/Central Texas(210) 340-2885
TexasCruz, TedSoutheast Texas(713) 718-3057
TexasCruz, TedWashington, D.C.(202) 224-5922
UtahHatch, OrrinCedar City(435) 586-8435
UtahHatch, OrrinOgden(801) 625-5672
UtahHatch, OrrinProvo(801) 375-7881
UtahHatch, OrrinSalt Lake City(801) 524-4380
UtahHatch, OrrinSt. George(435) 634-1795
UtahHatch, OrrinWashington, D.C.(202) 224-5251
UtahLee, MikeOgden(801) 392-9633
UtahLee, MikeSalt Lake City(801) 524-5933
UtahLee, MikeSt. George(435) 628-5514
UtahLee, MikeWashington, D.C.(202) 224-5444
VermontLeahy, PatrickBurlington(802) 863-2525
VermontLeahy, PatrickMontpelier(802) 229-0569
VermontLeahy, PatrickWashington, D.C.(202) 224-4242
VermontSanders, BernieBurlington(802) 862-0697
VermontSanders, BernieSt. Johnsbury(802) 748-9269
VermontSanders, BernieWashington, D.C.(202) 224-5141
VirginiaKaine, TimAbingdon(276) 525-4790
VirginiaKaine, TimManassas(703) 361-3192
VirginiaKaine, TimRichmond(804) 771-2221
VirginiaKaine, TimRoanoke(540) 682-5693
VirginiaKaine, TimVirginia Beach(757) 518-1674
VirginiaKaine, TimWashington, D.C.(202) 224-4024
VirginiaKaine, TimWashington, D.C.(202) 224-4024
VirginiaWarner, MarkAbingdon(276) 628-8158
VirginiaWarner, MarkNorfolk(757) 441-3079
VirginiaWarner, MarkRichmond(804) 775-2314
VirginiaWarner, MarkRoanoke(540) 857-2676
VirginiaWarner, MarkVienna(703) 442-0670
VirginiaWarner, MarkWashington, D.C.(202) 224-2023
WashingtonCantwell, MariaEverett(425) 303-0114
WashingtonCantwell, MariaRichland(509) 946-8106
WashingtonCantwell, MariaSeattle(206) 220-6400
WashingtonCantwell, MariaSpokane(509) 353-2507
WashingtonCantwell, MariaTacoma(253) 572-2281
WashingtonCantwell, MariaVancouver(360) 696-7838
WashingtonCantwell, MariaWashington, D.C.(202) 224-3441
WashingtonMurray, PattyEverett(425) 259-6515
WashingtonMurray, PattySeattle(206) 553-5545
WashingtonMurray, PattySpokane(509) 624-9515
WashingtonMurray, PattyTacoma(253) 572-3636
WashingtonMurray, PattyVancouver(360) 696-7797
WashingtonMurray, PattyWashington, D.C.(202) 224-2621
WashingtonMurray, PattyYakima(509) 453-7462
West VirginiaCapito, Shelley MooreBeckley(304) 347-5372
West VirginiaCapito, Shelley MooreCharleston(304) 347-5372
West VirginiaCapito, Shelley MooreMartinsburg(304) 262-9285
West VirginiaCapito, Shelley MooreMorgantown(304) 292-2310
West VirginiaCapito, Shelley MooreWashington, D.C.(202) 224-6472
West VirginiaManchin, JoeCharleston(304) 342-5855
West VirginiaManchin, JoeEastern Panhandle(304) 264-4626
West VirginiaManchin, JoeFairmont(304) 368-0567
West VirginiaManchin, JoeWashington, D.C.(202) 224-3954
WisconsinBaldwin, TammyEau Claire(715) 832-8424
WisconsinBaldwin, TammyGreen Bay(920) 498-2668
WisconsinBaldwin, TammyLa Crosse(608) 796-0045
WisconsinBaldwin, TammyMadison(608) 264-5338
WisconsinBaldwin, TammyMilwaukee(414) 297-4451
WisconsinBaldwin, TammyWashington, D.C.(202) 224-5653
WisconsinBaldwin, TammyWausau(715) 261-2611
WisconsinJohnson, RonMilwaukee(414) 276-7282
WisconsinJohnson, RonOshkosh(920) 230-7250
WisconsinJohnson, RonWashington, D.C.(202) 224-5323
WyomingBarrasso, JohnCasper(307) 261-6413
WyomingBarrasso, JohnCheyenne(307) 772-2451
WyomingBarrasso, JohnRiverton(307) 856-6642
WyomingBarrasso, JohnRock Springs(307) 362-5012
WyomingBarrasso, JohnSheridan(307) 672-6456
WyomingBarrasso, JohnWashington, D.C.(202) 224-6441
WyomingEnzi, MichaelCasper(307) 261-6572
WyomingEnzi, MichaelCheyenne(307) 772-2477
WyomingEnzi, MichaelCody(307) 527-9444
WyomingEnzi, MichaelGillette(307) 682-6268
WyomingEnzi, MichaelJackson(307) 739-9507
WyomingEnzi, MichaelWashington, D.C.(202) 224-3424

Feel free to ask your SMA expert consultant any questions you may have on this topic.
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Straight, No Chaser: Understanding an Actual Conservative Point of View on Healthcare

I am not attempting to speak for any group as much as I am hoping to enlighten those needing it regarding how others could seemingly vote for or support what appears to be in their “best interest” when it comes to health care.
For starters, not all Americans share the same value system. In as much as the citizenry has responsibility for our healthcare (via insurance payments, deductibles and co-pays that total thousands of dollars a year on average), it is properly described as a commodity. Among people with relatively scarce resources, consider these two scenarios:

  • Some people have higher priorities in their lives than healthcare. People who feel this way would love to spend those extra thousands of dollars on food, better education or whatever they choose. A government-mandated healthcare system prevents them from making decisions on how they spend their own money. Yes the assumption here is that they’ll never get sick, but many people are willing to accept the consequences of their choices.
  • Some people would rather manage their own healthcare. Many people do so successfully. In fact, insurance itself is largely based on the notion that you pay into the system more than you get back when you’re young and statistically don’t need healthcare (especially if you’re young and male), only to receive more than you pay into the system when you’re older and invariably going to need more healthcare. Again, there is a large group of Americans willing to accept responsibility for their own healthcare and/or health actions, if that means they can forego spending thousands of dollars into a healthcare system they largely don’t use, or if the option existed to buy healthcare on an as needed basis.

Next, there actually are legitimate concerns (that everyone seems afraid to discuss) about the cost of healthcare. If I told you there actually is $800 million dollars (roughly the amount slated for cuts to Medicare) of fat in the system, would you listen or just reflexively assume someone was trying to kill Grandma? Allow me to explain, but it’s important to point out that looking for efficiencies and savings in the system is not the same as justifying cuts to essential services as an excuse for tax cuts for the wealthy.

The amount of cash in the US healthcare system approximates $3 trillion and is over 17% of the gross domestic product (would you believe it was only 5% in 1960?). This comes to almost $10,000/year for every person in the country. It is estimated that the country that is next on the list of highest percentage of its GNP spent on healthcare is France, at about 11%. Yes, now is when I remind you that the US healthcare system historically has been ranked in the mid-thirties regarding best healthcare systems. So with that in mind, don’t tell me this great country can’t build a better system. Here are just three considerations about which those on both the left and right should be able to agree are problems.

  • Clinical inefficiency. Simply put, an ounce of prevention is worth a pound of cure. Using the ED instead of a family doctor’s office for the same presentation costs about eight times more. Also, eliminating the system of incentives for defensive medicine (meant to avoid lawsuits) would alone save almost $50 billion/year, according to the Harvard School of Public Health. In all, clinic waste accounting for 14% of health care spending, over $420 billion dollars.
  • Administrative complexity: This is so easy you should question the motives of those who haven’t brought this to pass. According to the Harvard Business School, fully 9% (about $270 billion a year) is wasted on inefficiencies in medical billing, collections, compliance and oversight. It’s the paper pushers.
  • Insurance companies: The next time someone whines about woe-is-me insurance companies, remind them that the companies participating in Medicare Advantage plans received about $170 billion, just from the government in 2015! Look at the below graph to see how well they all are doing. Have your stocks increased 1000% since 2009? The current model of paying insurance companies so much money is neither producing good outcomes for patients nor payers. Those on the left should be furious that better health isn’t included as a result of the thousands of dollars spent, and those on the right should be furious that the current system does not offer sufficient competition or transparency that could generate downward price pressure. Even more onerous, the various subsidies given to insurance companies are simply forms of corporate welfare, as multiple companies make tens of billions of dollars in profit each year.

So…next time someone talks about raising premiums on us, let’s ask about getting a better return on our investment.

If I may, here’s five simple components of what an actual compassionate conservative (i.e. even more so than Obamacare) plan would look like.

  • Freedom to opt out of healthcare insurance, with the caveat that one either participates in an “essential coverage plan,” or maintains a certain amount of financial liquidity (e.g. a health saving account) to pay for a year’s worth of projected costs based on actuarial tables. “Essential coverage” includes preventive medicine, critical care, maternal care, mental health and ongoing coverage of preexisting conditions – otherwise, it’s not really insurance.
  • Enhancement of competition, including the ability for insurance companies to compete across state lines as well as the items discussed in the next two bullet points.
  • Freedom for citizens to opt-in to a government option. Why, you ask, would this work for conservatives? Well, it’s about choice, and here’s an option. Also, the government option is the surest way to create downward price pressure.
  • Transparency in healthcare services pricing. As an example, if this existed, consumers would be able to decide for themselves if they wanted to pay for an MRI vs a CT scan vs an x-ray vs nothing for a knee sprain. Much has been made about the effects of price transparency on the cost of lasik surgery.
  • Dramatic savings earned by elimination of clinical waste and the resultant high costs of care, including the practice of defensive medicine and awarding of excessive medical malpractice rewards. Implementation of best practices in administrative processes, and ongoing crackdown on healthcare fraud and abuse (the Harvard Business School identifies these components as contributing to 40% of the costs of healthcare).

If a system was being proposed built on the above considerations by those on the right side of the political aisle, it would form the basis of an actual conservation and would result in even more cost savings, because there is in fact more than enough money already in the system to provide whatever services are needed. Imagine if you will that the US spent the same percentage of its GDP on healthcare as the second most generous nation on earth (France at 11%). That would represent a trillion dollars in savings, and remember: France provides universal healthcare with better healthcare outcomes.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
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A Straight, No Chaser Approach to Fixing Healthcare

The government may have “moved on” from healthcare, but we the people haven’t. This Straight, No Chaser addresses some very simple fixes for the Affordable Care Act (ACA). For starters, let’s operate under a few assumptions that may or may not be true, based on the recent efforts with the American Health Care Act (AHCA):

  1. The government has come to understand that the American public believes healthcare (or at least access to it) is a right.
  2. The government has come to understand that it must have a role in protecting the interests of the American public regarding how healthcare is delivered.

I also offer a third assumption that the American public would do well to understand about our nation’s healthcare product:

  1. Healthcare in the United States is an industry, not a system. With between $2-3 trillion in commerce being exchanged, the government is not going to bankrupt the insurance, hospital and pharmaceutical industries by putting in place a socialized medicine model (which frankly is not necessary to guarantee universal healthcare). Practically speaking, when speaking of a “uniquely American” solution, a heavy dose of capitalism will come into play for any reform efforts made.

Here are three principles and nine specific suggestions that members on both sides of the aisle (unless acting in a purely ideological manner, meaning either only socialized medicine – government-owned, operated or controlled hospitals, pharmaceutical, and healthcare providers – or no governmental involvement in the business of insurance companies providing health coverage and letting the free markets figure things out) could agree would improve the Affordable Care Act, or more importantly would improve healthcare under any system.

  • Expand the number of participants. The reason to do so is simple: the more individuals that are compelled to participate, the more risk sharing exists, allowing for overall cost reductions because of risk pooling. Options for doing this include the following.
    1. Continue the expansion of Medicaid. Kansas and North Carolina are already primed to become the 32nd and 33rd states to expand Medicaid under the ACA. Before President Trump was elected, Georgia, Idaho, Nebraska and South Dakota were considering Medicaid expansion, and now that the AHCA has been pulled, they will likely revisit consideration.
    2. Eliminate the individual mandate and replace it with a provision by which the government collects a tax in the same way social security and certain other taxes are collected, thus making the individual mandate “invisible.” Furthermore, means test the cost of insurance based on income and your choice of services, instead of by age. Individuals are going to need and use healthcare in the same way that police and public schools are used (Note this is not the same as forcing individuals into using public healthcare and removing choice). If people are going to use it, why not compel everyone to buy into the system? And while you’re at it, once you’ve means tested the cost of insurance based on income, then real consideration can be given to removing the employer mandate.

  • Increase competition. Yes, there is unnecessary waste in the system. Let’s work to bring costs down by embracing the capitalist construct of competition. Here’s a few simple ways how.
    1. Allow for competition by insurance companies across state lines. Competition everywhere will promote lower prices.
    2. Allow for purchase of pharmaceutical products from Canada and wherever quality can be assured.
    3. Provide a “public option.” If it is a bridge too far for the government to influence the costs of healthcare by setting prices directly to insurance companies, pharmaceutical companies and hospitals, providing an actual government-run insurance product option in which such price-setting did occur would compete with and compel these entities to fall in line.

  • Drive utilization toward less expensive, more efficient products
    1. Provide transparency in pricing. Have you ever noticed how rare it is for you to have any idea what the cost of services is? How can that make sense? For many forms of care, there are a range of services within the standard of care. Allowing patients to act as informed consumers can serve the purpose of lowering costs without reducing quality.
    2. Allow for bundling of services: Along the same lines as promoting transparency, moving away from separate fees for every individual service, medicine and gauze used and toward charging standard fees for different categories of services can create huge opportunities for savings and efficiencies.
    3. Maintain the “essential services” the “80/20 Rule”. Simply put, an ounce of prevention is worth a pound of cure. The more preventive and basic (essential) services are utilized, the better health outcomes become and the lower costs end up. The 80/20 rule (aka medical loss ratio) requires insurance companies to use 80 cents of every one of your dollars spent on your medical claims and specific activities meant to improve the quality of healthcare (if and when they don’t, you get a rebate).
    4. Rethink utilization of the emergency department and ambulance services. Millions of ambulance runs each year only represent the equivalent of taxi rides. Utilization of emergency departments occurs without any determination that other components of the healthcare system couldn’t be used, and for approximately thirty years, ERs have operated under an unfunded mandate to provide expensive varieties of the same care that could be rendered in a primary care office. This is a huge problem in that it has continually been shown that approximately 80% of ER visits could be effectively addressed by other healthcare options, and it’s also an issue because ER visits are approximately seven times the cost of using a family practitioner for the same presentation. This represents billions of dollars annually, and it’s also a major contributor to hospital costs representing the primary cause of personal bankruptcies. Just because you’re not paying upfront doesn’t mean you won’t be held responsible later. It’s time to implement some form of selective approval of ambulances and emergency room usage.

If you read back over these three principles and nine suggestions, you may find it shocking that none of these common sense suggestions is fully in place within our healthcare system except for the “80/20 Rule” and the mandate for essential services (both of which were meant to be eliminated under the recently proposed American Health Care Act). Implementing these suggestions brings us closer to coverage for all citizens, increases competition, and promotes quality. Who cares what the plan is called?
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
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Straight No Chaser In The News: The Real Costs of the American Health Care Act

This blog strives to provide medical and public health information – not to serve a political agenda or display any other forms of bias. It is not a means of generating income or serving sponsors. It is with that in mind that I ask our tens of thousands of readers and supporters to consider the following five truisms you should think about deeper that the ongoing slogans would have you do. With a Congressional vote coming today, forget what you’ve heard about the American Health Care Act (AHCA) being Obamacare-light (aka Affordable Care Act, ACA). There are monumental differences between the two. This is literally your life (and how you’ll protect it) that is being placed at risk.

  • The price of healthcare is going to continue to go up no matter what. Healthcare is an industry run by corporations, not the government. As such, corporations have a responsibility to their shareholders to generate as much profit as possible. This fact will remain the same under any plan that does not include a government-run consideration such as “Medicaid for all.”
  • The rate of rise of healthcare costs went down under the Affordable Care Act. One of the major goals and accomplishments of the ACA (aka Obamacare) is although costs continued to rise, it did so at the lowest rates in generations – this was by design. Consider this: according to FactCheck.org, during President Bush’s last six years in office, the average family insurance premiums increased 58% ($4,677). During President Obama, premiums went up by 33% ($4,154). Yes, costs went up (a lot), but the rate of rise slowed – and for what it’s worth, it’s amazing that no one ever seems to get much upset at insurance companies and other for-profit entities that actually are behind the increases in cost. The ACA never was insurance. It was an insurance marketplace where insurance companies agreed to provide insurance and compete for your business. You might as well be mad at the government for the cost of fast food. It’s a distraction.

  • A common refrain is “the costs of healthcare will go down!” Well, that’s government cost due to so many people losing their insurance. The cost of healthcare to you individually would skyrocket under the proposed AHCA (American Health Care Act). There are several reasons why. First of all, 24 million of you won’t have insurance, so you’ll be paying cash. Guess what? Cash rates are way higher than the rates charged to insurance companies. Also, those of you who don’t have insurance will be using the emergency rooms a lot. Well, the cost of ER visits is approximately seven times that of a family practice visit for the same presentations, and guess what? The cost of emergency services is one of the many items no longer to be covered under the AHCA. Also, those of you with insurance costs can expect it to skyrocket for two reasons: one, the law specifically eliminates customer protections (those nasty regulations) that fix insurance companies costs. Even if you believe in the free market’s ability to control costs, this is not that model. This will be a (not close to) free-for-all. Here’s one example: the ACA imposed a 3:1 limit on age rating, which restricted insurers from charging the elderly more than what younger citizens paid within the same area. Under the AHCA proposal; the limit will increase to 5:1. This is a huge reason why the AARP and other senior advocacy groups have come out against the AHCA. An AARP commissioned study concluded that for those over age 55 with a $25K annual income, the premium increase would be approximately $3,600/person, and a 64-year-old with the same income would see an increase of $7,000/person. If you’re 64 with an income of just $15K, your premium would cost $8,400 – more than half of your income. This is logic, math and greed. Remember the individual mandate that many seem to hate creates cost averaging. The more young, healthy people compelled to be in the ACA exchanges created a bigger pool to offset the increased costs of the elderly. With no mandate, there’s less money and no risk sharing.
  • The current conversation about healthcare is a nearly trillion-dollar tax cut in disguise (by eliminating the employer mandate), but what you really should be concerned about is the notion that the underlying “new normal” in play is Healthcare Is Not a Right. Folks, 24 million Americans are estimated to lose their insurance. That means many of you will immediately be placed in a situation in which you will have to decide whether to spend your disposable income on food or healthcare (including medicine). It means in many instances, whatever is wrong with you won’t be discovered until you’re in an emergency room and it’s too late, and/or the opportunity for a full recovery won’t be nearly what it would have been with primary care or preventive efforts. As if that’s not enough, the facade of insurance will become the norm. Your “new” AHCA insurance will not cover ER visits, hospitalizations, laboratory services, prescription drugs, maternity and newborn care, pediatric services (oral and vision care), preventive and wellness services, chronic disease management, mental health and substance use disorder services, rehabilitative services and devices. Get ready for personal bankruptcies to go through the roof.

  • There appears to be no airspace being given to the other fundamental healthcare option. As mentioned in the beginning, the narrative presuming that healthcare is not a right. The US stands alone among the civilized world in not providing universal health care. Once upon a time, the current President actually insisted that everyone needed to be covered. Where is the conversation regarding providing insurance or coverage for all in the same way police protection, education (for now) and a safety net for (some of) the most vulnerable? The goal of distraction is invariably to move away from the more important consideration.

As a reminder (or in case you didn’t know), here’s the 11th hour reason there aren’t enough votes within the Republican caucus to carry the vote at this time. President Trump’s final offered deal – a concession to replace the ACA’s mandate that insurance plans provide even a minimal level of “essential” benefits – was deemed not good enough, because the more conservative members (the “Freedom Caucus”) wanted a complete repeal of all ACA regulations, including such things as mandatory coverage for preexisting conditions and the ability to stay on one’s parents’ insurance until age 26. For the record, recent negotiations in an effort to gain passage in the House of Delegates have revised financial projections (by the non-partisan Congressional Budget Office) such that if passed, the AHCA is now expected to reduce the deficit by $150 billion over 10 years, a decrease from the $337 billion initially projected, while still forecasting a loss of insurance by 24 million people over a decade.
I really wonder if the population knowingly has empowered the Congress to completely obliterate its interests over whatever the perceived shortcomings of the Affordable Care Act are. I especially wonder if those in power actually believe they will get away with such a consequential redistribution of money to the rich and a complete destruction of the remnants of what passes for a healthcare system in this country.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK offers. Please share our page with your friends on WordPress, like us on Facebook SterlingMedicalAdvice.com and follow us on Twitter at @asksterlingmd.
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Straight, No Chaser In The News: The Real Meaning of the American Health Care Act and of Replacing the Affordable Care Act

Here’s the thing. It’s only one view that America bends toward an arc of diversity, inclusion and justice. There is another view – felt to be every bit as compelling to those who just happen to be represented by those who won the last election and control the various branches of government. In this view, personal responsibility and individual freedoms are the compelling freedoms of America, and redistribution of wealth toward the less fortunate is labelled an “entitlement” instead of part of what binds a nation together.

These competing interests have long played out in healthcare. It explains the reason that America has long been the sole major industrialized nation in the entire world that doesn’t provide universal health care and, by a large amount, demonstrates disparities in healthcare largely attributable to one’s financial status.
To say that America is a democracy is to say there are roughly equal parts liberal and conservative forces that can influence policy if and when given the opportunity. However, America is a capitalist nation without a counterbalancing force toward socialism. Historically, part of the social construct of nations with its citizens has been to, at a minimum, provide certain protections equated with socialism, including health, education, welfare and police protection. It is of interest to note that, in our capitalist society, there have always been efforts to further the capitalist experience and privatize these fundamentals. In the example of healthcare, these forces have outweighed the calls from those seeking universal healthcare or consideration of healthcare as a right.

It is in this vein that I view the current conversation on health care. One must appreciate the United States does not have a healthcare system. We have a healthcare industry that represents 1/6th (17%) of the U.S. economy (comparatively, the next largest country spends approximately 11% of it’s gross domestic product on healthcare). Appreciate this point. Of all the corporate “too bigs to fail,” the healthcare industry is especially legitimate. To shrink the healthcare industry by compelling a truly socialist healthcare system (meaning assets are owned and run by the government, complete with cost controls) would drive so many industries out of business, it would crash the economy beyond recognition. Right about now, for those of you who’d state that “healthcare for all” is the “right thing to do,” I should remind you that capitalism has no moral check. It’s governing principle is the so-called “invisible hand,” describing a force in a society in which everyone is pursuing their own individual gains, and in which the sum total of these efforts will generate desired end results across the board.
And so with healthcare, the purely capitalist approach would be to deliver care in total to the markets and the entrepreneurs chasing profits. Theoretically, competition would drive down costs and increase services in order to better attract customers. In this example healthcare outcomes are an offshoot of the industry, not the primary concern of a system.

Let’s look at five defining features of the American Health Care Act. I’ll list some facts first, then provide a bit of commentary.

  1. There will no longer be either a requirement or an entitlement to have health insurance. Of course this means there will no longer be a government-sanctioned entitlement to healthcare for all. If you believe in “personal responsibility,” you applaud this consideration. If you believe in a “social safety net,” not so much. Additionally, many of the taxes in place to fund the ACA would be eliminated.
  2. There will no longer be an employer mandate to provide health insurance. The employer mandate, which required companies with 50 or more full-time workers to offer insurance or pay a tax, will be going away. For many, the first impulse is to ask how employers could be so heartless. For others, the first question involves why employers have to provide insurance anyway. It was established a century ago as a competitive measure by companies, and later it became a requirement with the success of American unions. It just happens to be the case that the same levels of competition for employees and needs to provide benefits no longer exist, and employers are anxious to enjoy greater profits where possible.
  3. The Medicaid expansion created with the Affordable Care Act (aka ACA, Obamacare) will be phased out by 2020. For states having accepted the expansion, this will affect low-income families, pregnant woman, children, the disabled, and those over age 65 with incomes up to 138% of the federal poverty level (about $16,643). In this context, phased out means there will be no new enrollment and anyone allowing a lapse in coverage for more than one month will not be allowed to enroll.
  4. If you have commercial insurance, the so-called essential health benefits established under the ACA will remain. These include maternity care, mental health care and prescription drugs. Beginning 2020, state Medicaid plans would not have to meet this requirement. Additionally, young adults under age 26 will still be able to remain on their parents’ plans and insurance companies will not be able to deny insurance to those with preexisting insurance, given these individuals have preexisting insurance. However, under certain conditions, insurance companies will be allowed to charge up to 30% higher premiums for one year to such individuals.
  5. Financial assistance to help purchase insurance will change significantly from the ACA. The new plan would shift tax credit to those purchasing insurance away from income-based considerations to age-based considerations, even though insurance companies will be allowed to charge the elderly up to five times more for coverage than younger Americans. The net effect of this will be a lot less use of the system. Your insurance card will have a lot less value dollar for dollar compared to what you’ve had historically.

If you are in a rush to declare this bill a failure, it’s because you are of the mindset (in step with the rest of the world) that health care is a right, and insurance is necessary to provide healthcare. Of course, the point is that’s not the objective of those seeking to eliminate the ACA; in fact, the plan retains many, if not most of the programmatic elements of the ACA. It’s not just the ACA that these politicians are looking to eliminate. It’s the idea that healthcare is a right. It’s any notion that the government should financially support an entitlement. It’s the notion that the free market wouldn’t best regulate services and costs. It’s the notion that employers should be forced to provide benefits in this manner. So when the Congressional Budget Office tells you that between 6-10 million less people will be insured than currently are, and there won’t be cost savings to the citizenry, remember: that never was the objective. Remember this, which is perhaps closer to the true motivation of those perpetually inclined to distract you while pursuing truer interests in a stealth manner: the 400 highest-earning households in the country would get an average tax break of $7 million per year under the proposed American Health Care Act.
In the meantime, here’s what is expected to complete “access to care” for all of the newly uninsured.

Feel free to ask your Sterling Medical Advice expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK offers. Please share our page with your friends on WordPress, like us on Facebook SterlingMedicalAdvice.com and follow us on Twitter at @asksterlingmd.
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Straight, No Chaser In The News: Anticipating The Repeal of Obamacare (Affordable Care Act)


Elections have consequences. At this point, we can move beyond mere speculation and look at the certainty that the Affordable Care Act (aka Obamacare, ACA) will be repealed at some point promptly upon inauguration of the new U.S. President. That decision will have profound effects on the healthcare of tens of millions of Americans. This Straight, No Chaser will briefly review the impact of a repeal of the ACA.
As recently as June, 2016 Republicans have put forth the components of legislation meant to replace the Affordable Care Act. This information is notable both in what it seeks to accomplish and what it seeks to remove.
Here are a few of the items from Obamacare this legislation specifically would have reversed:

  • It would have repealed the mandate for individuals to buy health insurance and for employers with more than 50 workers to provide it to employees.
  • It would have eliminated all fines for people and companies that failed to comply with the mandates.
  • It would have eliminated current federal subsidies to about 6 million low- and moderate-income Americans who buy their own insurance.
  • It would have rolled back ObamaCare’s expansion of Medicaid for the poor (adopted by more than 30 states)

There are other concerns not explicitly stated to be at risk but are expected to go away with the repeal of the Affordable Care Act.

  • Obamacare eliminated insurance companies’ ability to exclude those with pre-existing conditions.
  • Obamacare mandated an ability to keep children on their parents’ insurance until age 26.

affordable-care-copy1Here are the components in the proposal that are to “be expanded upon” in actual legislation, with my commentary.

  • A refundable tax credit for Americans who don’t have employer-provided insurance. Of course, a tax credit is only applicable if you have sufficient taxes from which a deductible can occur. For the millions of Americans at or below the poverty level, the costs of healthcare spent will greatly outpace any deductibility considerations, resulting in much higher costs to this group.
  • Expanding the use of private health savings accounts (HSAs). HSA’s are a good additional consideration for consumers, as opposed to funneling your money to insurance companies who still will work to charge you additional fees via deductibles and co-pays. The issue, of course, is many Americans can not afford depositing money into a HSA, leaving them uninsured and exposed to higher costs.
  • Allow insurance companies to charge young people less and older people more. This consideration aligns usage with costs (and thus seems fair), but it eliminates the leveling of costs that keeps insurance affordable for those individuals most likely to use the system (i.e. the elderly). The most significant anticipated net effect of this will likely be higher profits for insurance companies.
  • Funnel the costliest patients to subsidized “high-risk pools.” As noted above, high risk pools equal higher costs.
  • Restructuring Medicaid and Medicare. This represents a clear opportunity but also a defined risk. Efforts to streamline these legacy entitlement programs are indeed needed and would be welcomed if they result in a higher percentage of money being used for healthcare instead of administrative costs. The time to be concerned about “restructuring” is when healthcare coverage and services for those most at risk (the poor and elderly) become cut. Watch closely for this consideration.

Despite real needs to build upon and improve the Affordable Care Act, it has had some clear successes, including the following:

  • Federal subsidies are now in place to about 6 million low- and moderate-income Americans who buy their own insurance.
  • Medicaid coverage for poor Americans has been adopted by more than 30 states.
  • 6 million people in the United States have gained medical insurance coverage as a result of Obamacare.
  • Approximately 17.6 million Americans have gained medical insurance coverage as a result of Obamacare.

Simply put, in the absence of an equivalent or superior healthcare initiative, it is estimated that 24.5 million individuals will lose coverage by 2025 as a result of repealing the Affordable Care Act.


It is easy to believe the desire to eliminate the positive accomplishments of the ACA are more based in politics than in policy. It is shameful that the reform being discussed involves a move in the direction of less coverage more so than universal coverage. The United States continues to have the undesired distinction of being the sole major industrialized nation in the world not offering its citizens universal health care and viewing health care as a commodity instead of a right. Yes, elections have consequences. The clear statement from this election regarding your health is the following: more than ever, the citizenry bears an increasing responsibility for its own health.
The next Straight, No Chaser will address the real and perceived problems with Obamacare in the context of the American election and its imminent repeal.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
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Straight, No Chaser In The News: Presidential Candidates' Views, Public Opinion and the Future of Obamacare

obamacare approved

Let’s go off the grid and take a look at the intersection of Presidential politics, health care and public health. Of the three remaining Presidential candidates, each has a distinct point of view regarding the future of the Affordable Care Act (ACA, aka Obamacare).

  • Hillary Clinton generally says she would keep the ACA in place.
  • Bernie Sanders calls for replacing the ACA with a single-payer, federally administered system: “Medicare for All.”
  • Donald Trump has said he would repeal the ACA.


Approximately two weeks ago, Gallup polled Americans on these thoughts without identifying the Presidential candidate associated with the viewpoint. Consistent with past findings, the majority of US citizens support the idea of a fully federally funded healthcare system. Here’s the breakdown of those individual views.

  • 58% favor replacing the ACA with federally funded healthcare system;
  • About half would also be ok with keeping the ACA as is; and
  • Just over half would favor repealing the ACA. However, only 22% of Americans say they want the ACA repealed outright; those favoring repeal largely favor replacing it with a federally funded system such as the even more liberal “Medical for All” option.

sanders obamacare

The partisan division of reactions to these proposals by partisanship shows the expected patterns: Democrats and Democratic-leaning independents are highly likely to favor the two governmental options (retain the ACA or move to “Medicare for All”), while Republicans and Republican leaners are highly likely to favor repeal of the ACA.
Republican presidential candidate Donald Trump speaks at a campaign stop, Wednesday, March 30, 2016, in Appleton, Wis. (AP Photo/Nam Y. Huh)
Historically, when given a choice, Americans are philosophically more inclined to favor a private healthcare system than one run by the government. Americans are generally satisfied with their personal healthcare. Unfortunately in this example the mere statistics have never told the complete story. Even with a 90% satisfaction level, that leaves over 30 million Americans completely without healthcare and inclined to be completely dissatisfied. Here in this life or death paradigm, the “majority rules” consideration just isn’t enough to overlook the needs of the minority.
It will be interesting to see how the debate is framed as things move forward. In the meantime, it is also of interest to also note that in the news is the drop of the uninsured in the US to single digits for the first time in generations.
Feel free to ask your SMA expert consultant any questions you may have on this topic.
Order your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com, iTunes, Amazon, Barnes and Nobles and wherever books are sold.
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Straight No Chaser in the News: SCOTUS Acts and the Top Seven Facts You Should Know About the Affordable Care Act (Obamacare)

obamacare_150625.nbcnews-fp-360-200The US Supreme Court has reaffirmed the legality of the government’s ability to provide subsidies to the governmental healthcare exchanges established to deliver care in states not establishing their own exchanges. That makes this a pretty good time to review how the Patient Protection and Affordable Care Act (ACA) fits into the American healthcare landscape.
Let’s start with the data: as of March 2015, the US Department of Health and Human Services reported a total of 16.4 million people covered due to the ACA between the Marketplace, Medicaid expansion, young adults staying on their parents plan, and other coverage provisions. According to Gallup that translates to an uninsured rate of 11.9%, down from a high of 18% in 2013.


Now let’s compare this to the goals. In general, the ACA attempts a nifty set of tricks: it aims to add over 30 million previously uncovered Americans to insurance rolls while slowing the rate of growth of health care costs, then ultimately reduce the costs of care. This simultaneously makes insurance providers huge winners and slight losers (30 million new customers but less profit per customer), as well as hospitals, physicians and pharmaceutical companies, who are meant to make a little more money while working a lot harder for it. The basic premise is there’s already plenty of money in the system (America spends over 17% of the gross domestic product – over $2 trillion annually on health care; no other country spends more than about 11% of GDP on health care) to provide what we need. 

The ACA was truly a Republican initiative at birth, for those keeping score. It was born out of the Heritage Foundation (a conservative think-tank) and is more or less a combination of plans proposed by Bob Dole and executed by Mitt Romney in Massachusetts. It does not provide universal coverage or even “Medicare for all” (those would have been current Democratic ideas, although Richard Nixon proposed the same) or allow a governmental takeover of hospitals, insurance companies or physician practices (those would be socialized medicine). At it’s simplest, it’s a capitalist give to insurance companies of 30 million new patients with enhanced governmental oversight.
Here’s those 7 positive facts:
1)    The 80/20 rule: The law requires insurers to spend at least 80% of premiums on direct medical care. This nearly doubles historical trends. This is meant to expand care greatly in certain areas such as prevention and mental health. If and when this doesn’t happen, you’ll get a rebate check.
2)    Preventative care is being emphasized: you likely won’t have to pay a co-payment, co-insurance or deductible to receive services such as screenings, vaccinations and counseling.
3)    Preexisting conditions: Health plans can’t limit or deny benefits or coverage to anyone under age 19 because of the existence of pre-existing conditions. These protections will be extended to all ages beginning in 2014.
4)    Choice and ER access: You choose your own doctor. You don’t need a referral from your primary care doctor to see an Ob-Gyn doctor. You don’t need pre-approval to seek ER services outside of your plan’s network (e.g. when you’re out of town). This means those ridiculous out of network charges should go away.
5)    Young Adult Coverage: If your plan covers children, you can add or keep your kids on your policy until they turn 26, even if they’re married, don’t live with you or are otherwise eligible to have their own plan.
6)    Consumer Assistance Program: This strengthens your ability to appeal and fight decisions made by your insurance provider and guarantees your right to appeal denials of payment.
7)     End on Annual and Lifetime Limits on Coverage for all new health insurance plans by 2014.


The bottom line is up to 30 million American are being formally brought under the umbrella of the health care instead of relying on emergency departments or going without care.  Despite not being a perfect solution, if we were to list societal priorities, closing this gap to this extent is high enough on the list that the downstream consequences are less important as considerations.  As a public health initiative, this act will accomplish many things, including putting in motion changes in health care disparities due to the lack of access to care.  I would challenge all the ongoing critics of the ACA to answer one question whenever they have an argument about why they continue to oppose implementation of the ACA: “Is your concern worth leaving 30 million Americans without structured healthcare?”
Thanks for liking and following Straight, No Chaser! This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK offers. Please share our page with your friends on WordPress, like us on Facebook @ SterlingMedicalAdvice.com and follow us on Twitter at @asksterlingmd. Preorder your copy of Dr. Sterling’s new book Behind The Curtain: A Peek at Life from within the ER at jeffreysterlingbooks.com.

Straight, No Chaser: Contrasting Healthcare Reform In the U.S. and Halfway Around the World

 Thoughts from a crowded Starbucks in Jakarta, Indonesia

Over my career, I’ve been fortunate to have studied and assisted healthcare systems all over the world. This past week, Sterling Medical Advice had the pleasure, privilege and outright honor of being invited to spend a week in Indonesia with the U.S. Department of Commerce on a healthcare mission in what will be a recurring role. By way of introduction (in case you weren’t aware), Indonesia is the fourth most populous country in the world (right after the U.S.) with a population of approximately 252 million people. It is approximately the same size as the United States, and it is a democracy and a member of the G-20 (with the 17th largest world economy).


More relevantly, Indonesia is in the midst of becoming the largest country in the world to implement a system of universal healthcare for its citizens. That’s right: by 2019, Indonesia will have enrolled their entire population in a universal healthcare system that is not owned or run by the government. This is a living rebuttal to those who insist that universal healthcare is necessarily socialist medicine.
There are some interesting observations to be made and contrasts between the system design and our own healthcare system. The U.S. currently spends over $8000 per person on healthcare per year; in Indonesia the average spend will be $60/person. This translates into Indonesia spending approximately $15 billion annually on health care after implementation of its new system, compared with over $2 trillion spent in the U.S., inclusive of Indonesia’s goal of doubling its current contributions toward its citizens’ health as part of its healthcare reform.


Dr. Sterling with Dr. Hasbullah Thabrany, professor of health policy at the University of Indonesia in Jakarta and architect of the world’s largest healthcare system

Access will be the foremost priority in the new system of Indonesia, whereas in the U.S., choice is the core component. Still, reform efforts of both systems are prioritizing access; unfortunately in the U.S., access still usually means utilization of the emergency room as a last resort as opposed to having everyone connected to a primary care physician.
Both systems suffer from dramatic physician shortages. In the U.S. this shortage has been addressed by the expansion of numbers and responsibilities for physician assistants and nurse practitioners. Indonesia has yet to permit non-physicians to obtaining status as independently licensed practitioners. In Indonesia, medical schools are opening in an attempt to address the shortage over the long-term; this is not a policy priority in the U.S.
These comments aren’t meant to suggest one country’s approach is better or worse. Such opinions are best addressed by review of objective data. Prior to the implementation of the Affordable Care Act in the U.S. and the current effort in Indonesia, both countries were performing less that either would have wanted. The World Health Organization’s (in)famous rankings of various countries’ systems (based largely on access and outcomes) placed the U.S. system #38 despite being the most expensive and Indonesia’s #92 while being #154 in costs. On the other hand, the U.S.’ ongoing spending of $2 trillion annually on healthcare does wonders for our economy.


As much as anything, the successful implementation of a universal healthcare system in a country the size of Indonesia should encourage those in the U.S. who have long advocated for such here, meaning if the political will ever existed, it could be accomplished. Unfortunately, the ingrained financial interests here continue to outweigh the desires of the public health community.
In the meantime, appreciate that the basics of a country’s ideal healthcare system should be the tools you utilize as your personal healthcare system. Embrace prevention through diet, exercise, screenings, immunizations and healthy life choices. Obtain information and advice to help guide your health decisions. Find a primary care physician. Get prompt treatment when you need it. The benefits of good health are worth the effort at every level.
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Straight No Chaser: New Patient Rights Under the Affordable Care Act (ACA)

health care next

Did you know patients have a Bill of Rights? Actually, there’s more than one type of patient bill of rights, but in this Straight, No Chaser, we address patient rights and protections introduced as a result of implementation of the Affordable Care Act (aka ACA, Obamacare). These rights largely speak to the relationship you have with your insurance provider and apply to all plans since September 2010. In order to avoid following these rules, insurance providers would have to petition the U.S Department of Health and Human Service.
Here are some of the protections that apply to health plans under the new laws:

  1. Annual and lifetime dollar limits to coverage of essential benefits have been removed. (Essential benefits include doctor and specialist visits, home and hospice services, emergency services, hospitalization, preventive and wellness services, chronic disease management, laboratory services, prescription drugs, maternity and newborn care, pediatric services, mental health and substance use disorder services, and rehabilitative services and devices. Non-essential benefits include things like adult dental care.)
  2. People will be able to get health insurance in spite of pre-existing medical conditions (medical problems one had before getting insurance).
  3. You have the right to an easy-to-understand summary of benefits and coverage.
  4. Young adults are able to stay on a parent’s policy until age 26 if certain requirements are met.
  5. You’re entitled to certain components of health prevention and screening without paying extra fees or co-pays.
  6. If your plan denies payment for a medical treatment or service, you must be told why it was refused and how to appeal (fight) that decision.
  7. You have the right to appeal the payment decisions of private health plans. (This is called an “internal appeal.”) You also have the right to a review by an independent organization (“outside review”) if the company still doesn’t want to pay.
  8. Larger insurance companies must spend 80 to 85% of their premiums on healthcare and improvement of care rather than on salaries, overhead, and marketing.
  9. If you made an honest mistake on your insurance application, health insurance companies will no longer be able to eliminate your health coverage after you get sick. (They can still cancel coverage if you don’t pay premiums on time, if you lied on your application form or if they stop offering plans in your region.)
  10. If a company does cancel your coverage, they must give you at least 30 days’ notice.
  11. Premium increases of more than 10% must be explained and clearly justified.

Knowing your rights is an important way to ensure you are receiving the best care possible. Take the time to learn these rights, and use them to your advantage.
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Straight, No Chaser in the News: Reporting New Rankings on the US Healthcare System

Today’s Straight, No Chaser is another in which we comparatively analyze the performance of the U.S. healthcare system. It’s important that this be done. It’s not enough to assert we have “the best healthcare in the world” without using objective data to substantiate these claims. Unfortunately, by any objective measure of the totality of our system, we pretty clearly don’t have the “best” system in the world. What we have is the most expensive healthcare in the world, and for those at the very top levels (of wealth) in society, we have access to options that aren’t found many other places in the world, and it can be argued that these individuals have access to the best medical services in the world. But what about the rest of us, especially the 30 million Americans projected to be without healthcare, even after full implementation of the Affordable Care Act? What about the actual system?


For the fifth time in a row, including studies in 2014, 2010, 2007, 2006, and 2004, the United States has been ranked last in a review of eleven rich, industrialized nations’ health care systems by the Commonwealth Fund, a prominent healthcare think tank. The eleven countries compared include Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the US. The report clearly demonstrate that the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of health care access, efficiency, and equity.
It should come as no surprise that our failure to perform is squarely tied to the lack of access that results from not having universal healthcare. The US is the only country in the survey not having universal healthcare. Consider these resultant illustration:

  • 37% of Americans said they didn’t fill a prescription, visit a physician or seek recommended care because of the additional out-of-pocket cost considerations inherent in our system. Now compare this to 4% of citizens of the UK saying the same, and it becomes easy to understand how access to care produces better health care outcomes between countries., not technological advantages we may have. That 37% number was the largest among countries in the survey.

In case you’re interested in the study’s methodology, the report incorporates the following considerations:

  • Patients’ and physicians’ survey results on care experiences and ratings on various dimensions of care
  • Information from the most recent three Commonwealth Fund international surveys of patients and primary care physicians about medical practices and views of their countries’ health systems (2011–2013).
  • Information on health care outcomes featured in The Commonwealth Fund’s most recent (2011) national health system scorecard,
  • Information from the World Health Organization (WHO)
  • Information from the Organization for Economic Cooperation and Development (OECD)


I guess the obvious thought in your minds might be about the effects of Obamacare (the Affordable Care Act, ACA).

  • The data that contributes to Commonwealth Fund’s survey was collected before Obamacare took effect. The authors point out that the “historic legislation” represents an “important first step” to fixing some of the US’ persistent issues with high costs and lack of access to insurance. The health reform law hopes to expand insurance coverage to millions of Americans who have been locked out of the health care system, and that could finally improve the U.S.’s rankings in areas like access and equity.
  • But there are still some gaps, due to resistance to Obamacare’s optional Medicaid expansion, which would extend public insurance to additional struggling Americans, about six million of the country’s poorest residents are still left with no access to affordable health care whatsoever.

More from the report: “The claim that the United States has ‘the best health care system in the world’ is clearly not true…To reduce cost and improve outcomes, the U.S. must adopt and adapt lessons from effective health care systems both at home and around the world.”

 Medical-Symbol dollar

The lesson I would have you learn is to remember, the U.S. healthcare system is a capitalistic enterprise that delivers $2 trillion a year to various corporate interests. That is a statement of fact, not politics. The delivery of healthcare within this system is expected to be a byproduct of capitalism’s competitively-induced incentives to those in the business, with the expectation that the system will become the best it possibly can be as a result of pursuing that $2T. This is a completely different paradigm than building an outcomes-based system based on putting in place initiatives to accomplish the desired end results and competitively bidding down the costs to the system. We in the U.S. do not have that framework as our underlying focus. The presumption that “the market will fix” the ills of our system leaves us where we are relative to other industrialized countries. Even the ACA only seeks to build on and improve upon the existing system, not replace it with a system resembling those producing better outcomes at lower cost around the world.

healthcare spending pc

Until and unless the conversation and legislative efforts migrate toward universal health care (which is still possible incorporating a “distinctly American solution/system” – despite talking points to the contrary, providing universal health is not necessarily the same as “socialized medicine”), there is no realistic reason to assume these surveys will reveal anything much different that the current results. The confusion that exists in your mind is a belief that better healthcare outcomes are actually the focus of the system. It’s not. As is the case with many other things in our country, the answer is to be found by following the money.
To access the full report, go to http://www.commonwealthfund.org.
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Straight, No Chaser: Here's When Your Sore Throat Needs Antibiotics – The Centor Criteria

I enjoy giving you tips that provide insight into what your physician is thinking. Some of these considerations are so simple that you can use them at home. In many examples, these can help you understand what to expect or even if a physician’s visit is even necessary.


For example, in revisiting sore throats, the big concern is whether you have strep throat. Not all sore throat are strep throat – in fact most aren’t. There’s scratchy throats from trauma, cigarette smoking and viruses, just to name a few non-strep throat causes of sore throats. As such, not all sore throats require antibiotics – in fact most don’t. However, all cases of strep throat require antibiotics. To not receive antibiotics for an actual strep infection can have devastating consequences, as discussed in this post.
Physicians use a set of criteria (the Centor criteria), based on clinical signs and symptoms, to identify the probability that your sore throat is strep throat. In case you’re wondering “Why not just do a test?”, the answer is those rapid tests done in the ER are very inconsistent and often inaccurate. Think about it this way: how still are you when someone’s sticking that swab in the back of your throat? Really, how persistent is your doctor or nurse in getting that swab all the way to the back of your throat? Many rapid strep tests are negative in the presence of real infection because the swab never got to the right area.



The criteria only involve four considerations. One point is assigned for each positive consideration.

  • History of fever above 101.4
  • Tonsillar exudates (those white patches you can see in the back of your throat)
  • Tender anterior cervical adenopathy (the swollen, tender “knots” in your neck found just about under the angle of your jaws)
  • Absence of cough (because the presence of a cough implies something else is occurring)

It’s worth noting that physicians may assign additional consideration to their decision to treat or not. If you’re less than 15, strep throat is more likely, and if you’re older than 44, it’s less likely.
The purpose of all this is it directs the need for testing and treatment.

  • 0 or 1 points – No antibiotic or throat culture necessary, as the risk of strep infection is less than 10%.
  • 2 or 3 points – You should receive a throat culture. You will be treated with an antibiotic if the culture is positive. The risk of strep infection here is 32% in the presence of three positive criteria and 15% in the presence of two.
  • 4 or 5 points – You should receive antibiotics. The risk of strep. infection is approximately 56%.

Whether you use this information for a better understanding of what your physician is doing on to empower you in utilizing the healthcare system, it’s good to know. Now get back to avoiding strep throat in the first place!

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Straight, No Chaser: This is What Change in Healthcare Looks Like…


In case you hadn’t noticed, the delivery of healthcare is undergoing a “Wild West” transformation. Although it’s been several decades (circa 1970s) since physicians actually controlled the healthcare system, a law called “The Corporate Practice of Medicine” prevented non-physician owned entities from practicing medicine (or influencing the practice of medicine enough to affect your care). With the contribution of $2.7 trillion dollars to the U.S. Gross National Product (GNP), perhaps it was inevitable that corporations would find a way to control all aspects of healthcare and reconfigure it as a business. Indeed, perhaps the single biggest reason the Affordable Care Act took its final form was because of the clarion call to repudiate socialized medicine (read as “embrace our capitalist system of healthcare”). Undoubtedly, the prominence and influence of insurance companies combined with the satisfaction most of the population has with its current care (“You can keep your doctor if you want!) played a major role in this.
What wasn’t as predictable was the influx of new entrants into the healthcare market. Perhaps we should have seen it coming, because anytime you’re offering one-sixth of the U.S. GNP – almost $3 trillion – you should expect major corporations to seek a piece of the pie. An early notable hint could have been detected in Wal-Mart’s decision in 2006 to begin offering generic drugs for $4. This was initially thought to be a tool to get folks into the stores (e.g., come for the generics, stay for the shopping). However, the move has proven to be much more ingenious than that.

  • If you’re a company as huge as Wal-Mart, you can make a profit off $4 items if your volume is high enough. They’ve proven that with many other products.
  • Most physicians write for more than one prescription at a time. Odds are, money is being made on some portion of your total prescription.
  • The innovation in offering transparency in pricing was a new and welcome development and created a level of trust and credibility to the Wal-Mart brand.

Let’s take a minute to explore that last bullet point. If you’re the world’s largest corporation, looking for new markets, have some credibility in healthcare and find barriers being torn down for healthcare delivery, wouldn’t the opening of one of the largest components of the American economy be an exciting opportunity? In short, it shouldn’t be a surprise when Wal-Mart begins providing some variation of medical clinics or some other means of providing healthcare.


However, this conversation isn’t limited to Wal-Mart and other chains that have already placed variations of treatment centers in their superstores or pharmacies. CVS pharmacies have stopped selling cigarettes. Telemedicine is becoming more and more prominent a part of healthcare. Healthcare is coming to your computers and smartphones. Prevention is expanding as a complement to the practice of medicine (www.sterlingmedicaladvice.com, anyone?). On another front, have you noticed there’s zero rush to replace the 45,000 shortage of physicians? Nurse practitioners and physician assistants will be your new providers and a major part of the new world order in healthcare, for better or worse.
Call it innovation, change, progress or whatever you like, but pay attention. This isn’t your parents’ healthcare anymore. Job #1 is for you to become more empowered and better stewards of your own care. Learn to find reliable, trustworthy sources for information and advice. This will get interesting.

This public service provides a sample of what http://www.SterlingMedicalAdvice.com (SMA) and 844-SMA-TALK (844-762-8255) offers. Please share our page with your friends on WordPress, Facebook @ SterlingMedicalAdvice.com and Twitter at @asksterlingmd. Please like and share our blog with your family and friends. We’re here for you 24/7 with immediate, personalized information and advice. Contact your Personal Healthcare Consultant at http://www.SterlingMedicalAdvice.com or 1-844-SMA-TALK.

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Feel free to ask any other questions you may have on this topic.

Straight, No Chaser: Sign Up For the Affordable Care Act – Today's the Deadline


Over 6 million of the previously 50 million American medically uninsured have already signed up for the Affordable Care Act (ACA aka Obamacare). Have you? Let’s consider this an open forum. Today is the deadline for signing up without penalty. It’s important that you realize what that means. I’m willing to answer any questions you have on signing up, penalties for not signing up and what it means to be enrolled.  In the meantime, refer to these past Straight, No Chaser blogs and refer to the governmental site at www.healthcare.gov.

I welcome any questions or comments. To get you started, here’s five quick points you should know.

  • In order to sign up, go to www.healthcare/gov or call 1-800-318-2596.
  • You can also buy policies directly from insurers. However, you won’t be eligible for premium tax credits that can reduce your costs. Those who purchase on the exchange and have an income between 100% and 400% of the poverty level may get tax credits to reduce their costs.
  • If you fail to sign up, the fine is $95 or 1% of your income after $10,150 — whichever is higher — for a single person this year. However, that penalty increases over time and with the size of your family.
  • To be eligible for health coverage through the ACA Marketplaces, you must live in the U.S. and be a U.S. citizen or national. You also can’t be in prison.
  • The cost of insurance vary dramatically, based on your income and family size. Check www.healthcare.gov for details.

Good luck, and good healthy!
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Straight, No Chaser: The Affordable Care Act and The Math of the US Healthcare System


As we begin 2014 with the implementation of the Affordable Care Act and states’ implementation of Medicaid expansion (well in most of the country), it bears reviewing why this was necessary. Joining me in this conversation is Dr. Bill Vostinak, a prominent orthopedist.
Prior to approval of the Affordable Care Act, and in spite of the loud and incorrect proclamations that we have the “best healthcare system in the world,” the U.S. would have been easily challenged on its purported effectiveness of our healthcare system based on a simple review of the following objective data points. (Our apologies in advance to those who value opinions over facts—or math.)


Let’s start by appreciating just how much the U.S. has been spending on our healthcare system and what type of access Americans have had to it.
The U.S., by a large margin, has the highest healthcare expenditures in the world. We spend approximately 17% ($1 in every $6) of our gross domestic product (GDP) on healthcare. The next closest nation spends 11%. (For clarification, that’s an incremental increase from the above chart of 2000.)
Despite our exorbitant national costs, only 84.9% of U.S. citizens have healthcare insurance. That translates to 50 million Americans who were uninsured prior to today. We rank 33rd in the world.
Have you ever heard the quote that “85% of Americans are happy with their healthcare?”  (Congratulations if that statement applies to you.) Do you realize that in a nation of over 320 million, that leaves 48 million Americans unhappy? Even if you got past the “48,000,000″ number, which is a massive number of citizens, consider the 85% number.
This is America. 85% is barely a B-grade in school. Is that the standard we seek? And … do the math. Notice the nearly exact match, likely not coincidental, between the number of individuals dissatisfied with their healthcare and the number of uninsured Americans. Basically, you’re satisfied if you have insurance, and if you don’t … not so much. Alternatively, 85% satisfaction may be based on the perception of insurance carrying the individual’s burden of medical costs.
Now let’s move to quality.
In an infamous ranking of healthcare systems around the world, the World Health Organization (WHO) ranked the U.S. system 38th based on routine outcomes-based metrics such as disability-adjusted life expectancy, speed of service, protection of privacy, quality of amenities, and fairness of financial contribution. WHO Ranking
Amid predictable criticism of the U.S. regarding the WHO study, Bloomberg performed its own analysis  and discovered that among advanced economies, the U.S. spends the most on healthcare (on a relative cost basis) with the worst outcome. Bloomberg ranked the U.S. 46th among all nations in efficiency given the average expenditure of $8,608 per year per individual. Bloomberg Report
In terms of infant mortality, about 11,300 newborns die each year within 24 hours of their birth in the U.S., with 50 percent more first-day deaths than all other industrialized countries combined. Infant Mortality
Save the Children’s 14th annual “State of the World’s Mothers” report ranked the U.S. 30th out of 168 countries in terms of best places to be a mother. Criteria included child mortality, maternal mortality, economic status of women, educational achievement and political representation of women. SaveTheChildren.org
An important distinguishing factor in comparing U.S. healthcare with other systems is tying it to employment rather than citizenship. Labor and other costs of American goods and services make it difficult for American corporation to compete in world markets. Add the large fixed cost of healthcare, and competing is nearly impossible.
It is reprehensible to suggest that the effort to cover 50 million uninsured Americans is some socialist plot or anything other than the humane thing to do. Let’s just stop with the selfishness and nonsense about there being no value to the efforts being made to improve access to/quality of healthcare (which reintroduces preventive and mental healthcare considerations) than we had previously. If you don’t believe us, just do the math. Even after a full implementation of the ACA, estimates suggest than some 20 million Americans will still be uninsured.
America is alone among the major industrial nations of the world in not having universal healthcare. That’s the collective decision of the country. Hopefully, these most recent steps through the ACA will represent significant steps toward efficiency, effectiveness and full inclusion. So, how do other countries deliver quality care for less? We’ll save that for another discussion.
Feel free to ask your SMA expert consultant if you have any questions on this topic.
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Copyright © 2014 · Sterling Initiatives, LLC · Powered by WordPress

Straight, No Chaser: A Solution to the Upcoming Healthcare Crisis and the Affordable Care Act

Many of you have heard or seen me discuss various aspects of the Patient Protection and Affordable Care Act.  This ambitious effort seeks to maintain the current level of quality that exists (via maintaining the same insurance coverage for those individuals that already have it), while adding approximately 30 million individuals to the insurance rolls while not increasing overall system costs.
Have you noticed that one part of the conversation that doesn’t seem to occur is “Who’s going to take care of these 30 million new individuals? Also, what about the other 20 million that still won’t have insurance?” The twin deterrents of co-pays and deductibles will eventually be stiffened to curtail over- and inappropriate utilization of the emergency room for both the newly insured and the uninsured voucher recipients (Besides, who wants to deal with the long wait times both in your physician’s office and the ER, soon to be even worse with all the newly insured?). Similarly, you would presume that armies of new physicians are being trained to meet this growth in the newly insured, but that simply isn’t the case. Additional options to address this influx will be necessary. Prominent among these options will be those providing better education and greater empowerment of patients to direct their own care.
Sterling Medical Advice (SMA) is a national public health initiative that provides a solution to these issues by the introduction of 24/7 online personal healthcare consulting, featuring physicians and other care professionals covering the entire spectrum of medicine and healthcare. Consultations will be personalized and immediately available to those in need around the clock.
“What’s that, and when might you use it?” Here are a few examples.

  • You need advice regarding an immediate medical concern
  • You need general information about your medical condition
  • You need immediate information about your prescription
  • You are experiencing symptoms and want to know why
  • You want to learn more information about a medical condition that is part of your family history
  • You want additional details on your upcoming medical procedure
  • You need advice regarding the best care option for addressing a medical concern (e.g., emergency room vs. urgent care vs. scheduling an appointment with your primary care physician)
  • You want a second opinion on your new diagnosis
  • You want a second opinion on your new treatment plan
  • You need additional information about what to expect from a newly diagnosed condition

Sterling Medical Advice will improve public health outcomes while reducing healthcare costs for individuals, families and businesses and the healthcare system at large. Personal healthcare consulting will create a better-educated and empowered population and will become an additional component to the American health care system without compromising quality.
To find out more about Sterling Medical Advice, visit www.sterlingmedicaladvice.com, and thanks for following Straight, No Chaser.

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