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More than 600,000 people signed up last week for health insurance under the Affordable Care Act, significantly beating the pace of prior years as consumers defied President Trump’s assertion that the marketplace was collapsing. (Pear, 11/9)

With only four days of data, experts said it's hard to discern a trend. But definitely the Affordable Care Act doesn't seem to be collapsing. If anything sign-ups for 2018 are on track with previous years. Figures from the Centers for Medicare and Medicaid Services showed that 601,462 people signed up Nov. 1-4 in the 39 states served by the federal HealthCare.gov website. Of those consumers, about 77 percent were renewing their coverage, and about 23 percent were new customers, a split that mirrors previous years. (Alonso-Zaldivar, 11/9)

Consumers are flocking to the Affordable Care Act (ACA) exchanges to buy insurance, setting a record in the first few days of open enrollment, federal numbers out Thursday show. Total daily sign-ups were up 79% for the first few days Healthcare.gov was open, compared to the equivalent period last year. Open enrollment started Nov. 1 and runs through Dec. 15. (O'Donnell, 11/9)

While CMS officials did not provide a direct comparison with any of the four previous enrollment periods, administration officials said that more than 200,000 consumers selected plans on the first day, more than double the number last year. The officials spoke about the first-day figure on the condition of anonymity because they were not authorized to disclose it. The overall total for the initial four days compares with just over 1 million Americans who signed up on the federal exchange during the first 12 days of open enrollment in 2016. (Eilperin and Goldstein, 11/9)

Insurers suggested the early influx was partly sparked by the spotlight on the ACA amid Republican efforts to repeal or change it. “You couldn’t have paid for that kind of advertising,” said Steve Ringel, president of the Ohio market for CareSource, which sells ACA plans in four states. “It doesn’t matter what the story line is, it’s drawing attention to the marketplace.” (Wilde Mathews, 11/9)

The pace of signups cheered supporters of the healthcare law, many of whom feared that President Trump’s criticism of the law, coupled with major cuts in federal funding for advertising and outreach efforts, would depress enrollment. At six weeks, the enrollment period is also only half as long this year, running until Dec. 15. (Levey, 11/9)

About 130,000 people were new customers this year, while about 460,000 were returning customers. (Sullivan, 11/9)

“All this discussion about repeal made people aware that, ‘Wow, I should be grateful for what I have access to,”’ said Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University in Fairfax, Virginia. “There’s just way more consciousness to the value of health insurance than before they tried to repeal it.” (Edney and Tozzi, 11/9)

The federal government hasn't set an enrollment goal as the Obama administration did for previous open enrollment periods. In 2017, 10.3 million people got coverage and paid their first month's premiums through the exchanges. (Livingston, 11/9)

Uber Technologies Inc and some smaller technology companies are launching campaigns to publicize Obamacare enrollment among their contract workers after the Trump administration slashed government marketing for the health program by 90 percent. Freelance and contract workers are an important part of the workforce for many Silicon Valley companies, including drivers at Uber and rival Lyft Inc, and technology companies also have been among the most vocal in confronting Trump administration policies - particularly immigration - that they perceive as hurting their workforce. (Rodriguez, 11/9)

Kaiser Health News: Obamacare Shopping Is Trickier Than Ever. Here’s A Cheat Sheet.

Health care is complicated. Shopping for an individual health plan just got even more so, with President Donald Trump’s decision last month to block $7 billion in Affordable Care Act subsidies. Known as cost-sharing reduction payments (CSRs), these federal funds had helped insurers offset the costs of the discounts they are required to offer to some lower-earning customers to help them pay for deductibles and copays. (Hancock, 11/10)

The ex-Obama officials leading the guerrilla effort to boost Affordable Care Act sign-ups are celebrating their first big win after CMS posted early enrollment numbers that are nearly double last year's pace — even though the Trump administration slashed outreach, ads and other messaging. (Diamond, 11/9)

Georgia officials involved with enrolling consumers reported Thursday that they have seen a steady flow of people looking to sign up for 2018 exchange coverage. (Miller, 11/9)

The fifth open enrollment period under the Affordable Care Act is off to a strong start in California, with 5,900 people signing up for new health insurance plans on Nov. 1 — 25 percent higher than the first day of open enrollment in 2016, Covered California officials said. Open enrollment runs through Jan. 31, and it is too soon to tell whether the pace of signups will continue, but the initial numbers are one early signal that Covered California’s aggressive ramp-up in advertising, marketing and outreach efforts is paying off. (Ho, 11/9)

The Republicans are losing their seven-year political advantage on health care, this week’s election results suggest, a shift that affects everything from candidates’ campaign messages to lawmakers’ policy choices to the level of enrollment for the Affordable Care Act. Republicans have won national and state elections for seven years by attacking the ACA. But this week, Virginia voters cited health care in exit polls as a major reason for delivering the governorship to Democrat Ralph Northam and Maine residents voted decisively to expand Medicaid. (Armour, 11/9)

This week's groundswell of political change in Virginia has improved the odds of Medicaid expansion becoming law there. The long-stalled liberal priority gained new life after Democrats nearly wiped out Republicans' overwhelming majority in the House of Delegates. For years Medicaid expansion, a key part of former President Barack Obama's health care law, has been a non-starter in the Old Dominion. (11/9)

Medicaid expansion advocates say Kansas policymakers should take notice of elections this week in Maine and Virginia. In Maine, lawmakers sent five expansion bills to Republican Gov. Paul LePage in recent years. He vetoed them all. So Maine voters took matters into their own hands Tuesday by overwhelmingly approving a ballot initiative authorizing expansion. (Mclean, 11/9)

President Donald Trump and Republican leaders in Congress have repeatedly said Obamacare is failing, or even dead. Yet there are signs across the country that support for the law’s programs is stronger than opponents have portrayed. This week in Virginia, where Democrats won a competitive governors race, Two-thirds of voters there called health care a “very important” or the most important issue, according to one poll. In Maine, the state voted to expand Medicaid under the law, something their Republican governor had sworn not to do. (Edney and Tozzi, 11/10)

The tax-reform bill that Senate Republicans are releasing Thursday does not repeal ObamaCare's individual insurance mandate, though the provision could be added down the line, GOP senators said. Senators leaving a briefing about the legislation said repealing the mandate is not in the initial text of the legislation, but cautioned that the issue is still under discussion. (Sullivan, 11/9)

Senate Republicans say they are still considering adding the provision, which conservative lawmakers and President Donald Trump have pushed to include in a tax overhaul. “At this point it’s not but there’s a lot of discussion on that and we're looking at it very seriously,” said Sen. John Hoeven, R-N.D. GOP leaders have resisted including changes to the Democrats’ health care law in tax legislation over concerns that could complicate its passage. Senate Republicans can only lose two votes under the budget reconciliation process to pass a tax bill without any Democratic votes.(McIntire, 11/9)

Repealing the mandate would result in $338 billion in extra revenue Republicans could use to make some of their tax cuts permanent, according to several GOP sources. It would also allow Republicans to make a down payment on undoing Obamacare, the campaign pledge they worked at unsuccessfully for nine months of the year. (Haberkorn, 11/9)

The Senate GOP tax bill will retain a key deduction for qualified medical expenses that was excluded from the House version, according to a Republican senator on the Senate Finance Committee. Sen. Bill Cassidy (R-La.) told reporters that the deduction will remain in the initial version of legislation the Senate is set to unveil today. (Weixel, 11/9)

The head of a powerful House committee on Thursday promised to review an array of health care issues ranging from Medicare to the exchanges to prescription drugs. Energy and Commerce Chairman Greg Walden, R-Ore., told physicians at a conference that he plans to examine issues such as broadening Medicare Advantage’s role in the new Medicare payment system for doctors, permanently authorizing Medicare plans for patients with complex medical histories​ and scrutinizing health care middlemen like pharmacy benefit managers. (Clason, 11/9)

With their hopes of repealing the Affordable Care Act dashed for now, deep-pocketed conservative activists have turned their attention to a smaller but still potent new effort: allowing private health care to compete with Veterans Affairs hospitals for the patronage of the nation’s veterans. Concerned Veterans for America, a little-known advocacy group backed by the conservative billionaire industrialists Charles G. and David H. Koch, is pressing Republicans to make it easier for veterans to see private doctors at government expense. The group’s voice had been lonely until recently, when a raft of Koch-connected advocacy organizations and other conservative allies joined the effort. (Fandos, 11/9)

Should the Pentagon be allowed to authorize the use of unapproved drugs and medical devices on an emergency basis for combat soldiers? That question has sparked a furious battle this week among some of Washington's biggest power players, with the Defense Department and its congressional advocates on one side and the Food and Drug Administration and the health committees on the other. (McGinley, 11/9)

President Donald Trump is pointing to big achievements in advance of Veterans Day on his campaign promise to fix the Department of Veterans Affairs, just 10 months into his administration. But several of the initiatives are far from bold or as immediate as claimed. In a two-page fact sheet this week, the White House declares that "tremendous progress has been made in a short period of time." (11/10)

Symptoms of terminal illnesses, like pain or breathlessness, can trigger flashbacks, making vets feel as threatened as they did on the battlefield. ...Some vets see their pain or PTSD as retribution for their work in the line of duty. (Dembosky, 11/9)

The U.S. Drug Enforcement Administration wants to make it easier for federal prosecutors to go after people who peddle illicit versions of the deadly opioid fentanyl that are fueling the nation’s drug abuse crisis. The agency said Thursday it intends to classify drugs that are chemically similar to fentanyl as illegal controlled substances, letting prosecutors avoid the hurdles they often face in bringing charges in such cases. (Gurman, 11/9)

The Drug Enforcement Administration (DEA) intends to temporarily schedule all fentanyl-related substances on an emergency basis, the Justice Department announced Thursday. That classification will let prosecutors charge people trafficking substances similar to fentanyl with the same charges as fentanyl, which is up to 50 times more potent than heroin. (Roubein, 11/9)

Under the administration’s action, anything that was considered a fentanyl analogue going forward would simply be a Schedule I drug subject to the same penalties as heroin, LSD and marijuana. Prosecution could still be a challenge, however, as most illicit fentanyl derivatives are made by individuals in China beyond the reach of American law enforcement. The Justice Department recently announced indictments of two Chinese nationals involved in fentanyl trafficking. While Beijing has signaled a willingness to cooperate on fentanyl, the United States doesn't have an extradition treaty with China. (Siddons, 11/9)

The Trump administration declared the opioid crisis a public health emergency two weeks ago. Six days later, a White House-appointed panel proposed a national drug court system, a dramatic increase in addiction treatment beds, and what President Trump called “really tough, really big, really great advertising” to warn of the perils of drug use. Neither the White House nor Congress has suggested how to pay for those measures. (Facher and Mershon, 11/9)

Sarah Bolin's heart infection got so bad last month, the longtime heroin user was passing out by the time she got to Cincinnati's Christ Hospital. She was relieved the infection — called endocarditis — didn't require her to get a pacemaker or replacement heart valve like so many other "girls on the streets." It did require surgery to remove lesions from infected valves, a 10-day hospital stay and weeks of IV antibiotics and nursing home care. (O'Donnell and DeMio, 11/8)

Republican Lt. Gov. Mary Taylor said Thursday that if elected governor, she would issue up to $1 billion in bonds to pay for private sector solutions to the opioid addiction crisis. ...Other planks in Taylor's opioid plan included moving state-funded health care systems away from prescribing opioids, directing them to alternatives like chiropractic care, massage therapy, physical therapy and mental health services. (Richardson, 11/9)

Four of Arizona's top opioid-prescribing doctors are located in sparsely populated Mohave County, an unusual pattern that has Gov. Doug Ducey asking if it might indicate widespread abuse of the pain pills. The four doctors, who were not identified, wrote prescriptions for nearly 6 million pills over a 12-month period. (Wingett Sanchez, 11/9)

On Oct. 21, a body was found off a county road west of Corpus Christi, Tex., with bullet wounds to the chest, abdomen and shoulders. The victim was Stephanie Montez, a transgender woman. But because the police misidentified her as a man, it was not until last week that Ms. Montez, 47, was known to be among the more than two dozen transgender Americans killed this year. (Astor, 11/9)

One in five adults in the United States was using some form of tobacco in 2015, according to national survey data released on Thursday by the U.S. Centers for Disease Control and Prevention. The report, conducted in conjunction with the Food and Drug Administration, found 21 percent of U.S. adults, or 49 million people, were tobacco users. Of them, about 87 percent reported smoking cigarettes, cigars or some form of pipe. (Steenhuysen, 11/9)

Fidget spinners — the multipronged, whirling gadgets that became so popular this year that some schools banned them as a distraction — have been marketed as playful diversions meant to help people calm down and focus. But now a consumer advocacy group says that two types of fidget spinners being sold at Target could be dangerous. The items — Fidget Wild Premium Spinner Brass and Fidget Wild Premium Spinner Metal — were found to contain as much as 330 times the federal legal limit for lead in children's products, according to lab tests conducted for the U.S. Public Interest Research Group, or U.S. PIRG, Education Fund. (Bhattarai, 11/9)

Kaiser Health News: Experts Explain Why Lead Found In Fidget Spinners Is No Idle Threat

That fidget spinner your kid can’t put down? It turns out it may be putting children at risk for lead exposure. That’s according to a report out Thursday from a consumer advocacy group, the U.S. Public Interest Research Group Education Fund. The organization tested the toys — which represent the latest iteration of a long line of skill-based amusements that include yo-yos and spinning tops — for lead. (Luthra, 11/10)

St. Joseph, population 1,029, is one of thousands of small towns across the country that have no access to safe, clean drinking water. ...Trump wants to eliminate the U.S. Department of Agriculture’s Rural Utilities Service, which awards water and sewer loans and grants to towns with 10,000 or fewer people. (Loftis, 11/9)

Despite advances in modern medicine, it's still a reality in America that you can go to the hospital for treatment, and end up sicker with a nasty hospital-acquired infection. How do these infections spread in our healthcare facilities, and what can patients do to protect themselves? (Miller, 11/9)

The city of Toledo and nearby communities have earned the dubious distinction of being the first to report outbreaks of human illness due to algae toxins in municipal drinking water, according to a report published Thursday by the Centers for Disease Control and Prevention. Both areas take their drinking water from Lake Erie. Blue-green algae are common there and in many other in freshwater lakes, were they can multiply in the heat of summer and produce toxins, according to the Environmental Protection Agency. (Jochem, 11/9)

People with Alzheimer's or dementia are plagued by more than just memory loss. A mother who was always calm may become agitated; an unfailingly kind father may turn aggressive or belligerent. Dementia affects brain tissue, and that can cause personality changes, says Dr. Diana Kerwin, chief of geriatrics at Texas Health Dallas and founder of Texas Alzheimer's and Memory Disorders. Restlessness, wandering, even delusions are common behaviors associated with dementia. Sometimes memory loss can also trigger paranoia. If Mom can't remember where she left her purse, she may accuse family members of stealing it. (Jacobs, 11/9)

Massachusetts senators approved a sweeping bill at midnight Thursday that seeks to control the rising costs of medical care and prescription drugs, including a controversial plan that would fine hospitals if spending rises too fast. The legislation also would require pharmaceutical companies to submit to more scrutiny from state officials. (Dayal McCluskey, 11/9)

Planning a visit to San Diego? Hit the beaches. Check. Spend a day at the zoo or a theme park. Check. Sample craft beer. Check. Book a stay at a local hospital for cutting-edge cardiac or cancer treatment? For decades, San Diego has traded on its reputation for year-round sun, a captivating coastline and family-friendly attractions to woo tourists. But enticing visitors with the promise of lifesaving treatments by acclaimed physicians and hospitals has never been offered up as a selling point. Until now. (Weisberg, 11/9)

Desperate to persuade young doctors to settle in rural areas — or just keep them from leaving the state — medical schools, hospitals, and state legislators are getting creative. They’re forgiving tens of thousands of dollars in loans, setting up mentorships, and recruiting med school grads with local ties in an effort to hold on to providers. ...But on this crucial metric, some states are faring far worse than others. California, with an abundance of space and jobs for doctors, retains 70 percent of residents and fellows trained in-state — compared to just 28 percent in tiny New Hampshire, where full-time physician jobs are few and leaving the state may only mean moving a short distance. (Robbins and Bronshtein, 11/9)

A website launched this week in Oregon to help consumers in disputes with health plans. The site, MyPatientRights.org, is directed at consumers who are denied coverage, experience delays or are unhappy with decisions by their health insurer. It lists patient rights, such as to see their personal health records and to keep those private. It lists some of the issues patients might face, such as co-insurance costs, high deductibles and adverse tiering, which involves a company putting all medications for a specific condition into the highest cost bracket. (Terry, 11/9)

California Attorney General Xavier Becerra on Thursday filed a legal motion asking a judge to halt the implementation of federal rule changes, announced by the Trump administration last month, that give employers more leeway to opt out of the Affordable Care Act’s contraceptive mandate. Becerra, along with the attorneys general of Delaware, Maryland, New York and Virginia, filed a request for a preliminary injunction in U.S. District Court for the Northern District of California in San Francisco. (Ho, 11/9)

Investors in Outcome Health on Thursday said in a court filing that they were receiving subpoenas from the Justice Department as part of a fraud investigation into the prominent Chicago advertising startup. The filing, submitted to the New York State Supreme Court in New York County, said Goldman Sachs Group Inc. and other investors, which are suing Outcome for allegedly defrauding them, were receiving the subpoenas on Thursday. The investors also said “additional inquiries” were expected from the Securities and Exchange Commission, without elaborating. (Winkler, 11/9)

The Justice Department is subpoenaing investors in Chicago-based Outcome Health in the wake of a lawsuit accusing the prominent health information and advertising startup of committing fraud to secure nearly $500 million in funding. The orders from federal investigators, revealed in court documents filed by investors Thursday, come as hospitals and health care advertisers back away from the fast-growing company, which places interactive screens and tablets in doctors’ offices. The court filing indicates investors also anticipate inquiries from the Securities and Exchange Commission. (Schencker and Marotti, 11/9)

The federal government is moving to dismiss a lawsuit it brought two years ago against a national nursing-care provider after a judge tossed out the government’s key witness over issues of credibility. The Justice Department joined in on a whistleblower lawsuit against Toledo, Ohio-based HCR ManorCare, which operates more than 250 skilled nursing facilities nationwide. Authorities say the chain fraudulently overbilled Medicare for millions of dollars. (Barakat, 11/9)

An investigation by a state watchdog agency has found that “high numbers” of children have left public school for medical or mental health reasons – though only two-thirds of the absences had been authorized by the student’s health care provider, as required by state regulations. (Thomas, 11/9)

HCA will train Meharry Medical College students at HCA's TriStar Southern Hills Medical Center, the organizations announced Thursday. HCA, the nation's largest hospital system with 177 hospitals, signed a memorandum of agreement that expands upon the relationship between the two Nashville institutions. It will give HCA access to medical students and allow it to leverage Meharry's global reputation for educating future primary-care doctors. (Kacik, 11/9)

A "historic" agreement between Meharry Medical College and HCA Healthcare will transform how the college trains its students and push its reach further into Davidson County. Under the agreement, Meharry students in their their third and fourth years will train at TriStar Southern Hills Medical Center, a hospital in HCA's TriStar Health subsidiary. (Fletcher, 11/9)

Mayor Megan Barry on Thursday announced plans to end inpatient care at Nashville General Hospital, the city’s only safety net hospital. Barry said her administration would submit to the Metro Council a “substantial request” for funds to stabilize the facility until the end of the fiscal year. Thereafter, Barry said, she would focus her efforts on transforming the facility into an ambulatory surgical care center, which would provide only outpatient services. (Wadhwani, 11/9)

The U.S. Department of Justice has scored hundreds of millions in settlements from nursing homes for allegations of fraudulent billing for therapy, but those efforts faltered Thursday in a whistle-blower case against HCR ManorCare Inc., one of the largest companies in the industry. Government lawyers, after being ordered this week to pay ManorCare’s attorneys the cost of a single filing in a dustup over a government witness, notified U.S. District Court for the Eastern District of Virginia that they were in agreement with ManorCare to dismiss the case. (Brubaker, 11/9)

Genesis HealthCare chief executive George V. Hager Jr. told investors Thursday that the nursing home company’s latest financial restructuring “a huge, huge step for us bridging to the recovery and moving to the next cycle of this industry.” Under the deal announced Wednesday, Genesis’s largest landlords Welltower Inc. and Sabra Health Care REIT Inc., will sell certain properties leased to Genesis. Genesis is then expected lease them from the new owners at lower rents. That rent reduction is expected to be $54 million annually starting in January. (Brubaker, 11/9)

East Houston Regional Medical Center, swamped by 6 feet of water during Hurricane Harvey in August, is closing for good in what is being called the biggest medical casualty of the storm. The 131-bed hospital, an institution in the region after 40-plus years in operation, was recently determined to not be salvageable after the storm roared ashore and devastated the area with historic flooding. (Deam and Ackerman, 11/10)

New Orleans Times-Picayune: New Orleans Woman Found Guilty In $3.2 Million Medicare Kickback Scheme

A New Orleans woman was found guilty Thursday (Nov. 9) of participating in a roughly $3.2 million Medicare fraud and kickback scheme that involved fraudulent billing for power wheelchairs and other medical equipment, according to federal officials. A federal jury convicted Sandra Parkman, who is in her 60s, of one count of conspiracy to commit healthcare fraud, one count of conspiracy to pay and receive kickbacks, two counts of healthcare fraud and five counts of accepting kickbacks. (McKnight, 11/9)

After Yarly Raygoza attended the drug prevention program at the Boys & Girls Club here last year, she used what she learned to talk a few friends out of using marijuana. The 14-year-old took the class again this year but worries that counseling her friends will become more difficult. (Gorman, 11/10)

Patients with advanced illnesses sometimes request that physicians help hasten their death. Increasingly in North America and Europe, legal options allow physicians to perform this role. Among death-hastening options, the spotlight has been on physician-assisted death. However, voluntarily stopping eating and drinking (VSED) is also a course that patients may choose. Although VSED theoretically does not require physician involvement, clinician participation is critical in terms of initial assessment and ongoing management. In this review, we examine both clinical issues in assessing patients who are considering VSED and the clinical challenges that may emerge during VSED. We also explore some of the underlying ethical and legal considerations for physicians who either care for or decline to care for these patients. Physicians who care for seriously ill patients should be prepared to respond to patients’ requests to participate in VSED. (Quill et al., 11/6)

Since 2006, the Medicare Part D prescription drug benefit has helped improve the affordability of medications for people with Medicare. Yet even with Part D, enrollees can face relatively high out-of-pocket costs because there is no hard cap on out-of-pocket spending under Part D. ... This analysis examines out-of-pocket prescription drug spending among Medicare Part D enrollees with costs above the catastrophic coverage threshold. ... In 2015, 3.6 million Medicare Part D enrollees had total drug spending above the catastrophic coverage threshold. Of this total, 2.6 million enrollees received low-income subsidies, but 1 million enrollees did not, and incurred out-of-pocket drug spending above the catastrophic threshold. (Cubanski et al., 11/7)

Question: Has the provision of preventive care for adolescents, in terms of a preventive well visit and preventive services, increased since implementation of the Affordable Care Act?Findings: This secondary data analysis of the Medical Expenditure Panel Survey, a national survey, showed that rates of preventive well visits for adolescents 10 to 17 years of age increased from 41% (2007-2009) to 48% (2012-2014). Among adolescents who received any health care visit in the past year, 8 of 9 preventive services rose, with increases ranging from 2% to 9%. Meaning: Preventive care rates have increased moderately or modestly; however, most adolescents did not receive past-year well visits or most preventive services. (Adams et al., 11/6)

In this prospective cohort study that included 1575 patients with stage I to III colorectal cancer, higher intake of fiber, especially from cereals, was associated with a lower risk of colorectal cancer–specific and overall mortality. Patients who increased their fiber intake after diagnosis from levels before diagnosis showed better survival; higher intake of whole grains was also associated with favorable survival. (Song, Wu, Meyerhardt, et. al., 11/2)

Perhaps this is the inevitable conclusion for someone only reading news headlines about the Department of Veterans Affairs, but I am honored to be a VA doctor. The other day, I was in a Lyft car (I am writing from San Francisco, after all.) chatting with the driver when I mentioned I work at the VA. He immediately opened up and shared that he was an Iraq War veteran and told me all about his primary care doctor at the VA and the support he received as he transitioned back to civilian life. He thanked me for my service to the veterans. I thanked him for his service to our country. This is the VA that I know, the VA that our country should be proud of. (Megha Garg, 11/10)

The Military Health System (MHS) is one of the largest health systems in the United States, delivering health services to 9.4 million eligible patients in nearly 700 military hospitals and clinics around the world as well as through the TRICARE health plan. ... The National Defense Authorization Act for Fiscal Year 2017 directs changes to existing management structures, enabling the MHS to collectively transform into an integrated system of readiness and health. ... This Viewpoint describes the strategic logic of a transformation that Sen John McCain (R, Arizona) stated was the “Most sweeping overhaul of the [MHS] in a generation.” (David J. Smith, Raquel C. Bono and Bryce J. Slinger, 11/9)

A 2018 budget blueprint approved by Congress late last month would reduce Medicare spending by $473 billion over 10 years compared with the current baseline projection, and proposes $1.3 trillion in cuts to Medicaid, various Affordable Care Act (ACA) tax credits and cost sharing subsidies and other health spending. Republicans need the spending reductions to make room for $1.5 trillion in tax cuts, mostly for corporations and wealthy households. The budget plan does not include the specifics on how these cuts will be achieved. (Mark Miller, 11/9)

Despite aggressive targets set by Medicare for the spread of value-based payment arrangements and widespread agreement on the importance of delivery-system reform, progress toward lower spending growth and a transformed delivery system has been slow. Accountable care organizations (ACOs) are a prime example: nearly 1000 organizations operate as ACOs, but they have generated limited savings. Even in the third year of Medicare ACO contracts, fewer than half of ACOs received a bonus for reducing spending. To guide policy and help providers succeed, it would be useful to understand why so few ACOs are achieving savings. Data-driven empirical work on ACO performance has yielded few insights into the specific characteristics of ACOs that lead to success. We believe it would be helpful to consider how economic and organizational theories might explain early results from the ACO experiment. (Valerie A. Lewis, Elliott S. Fisher and Carrie H. Colla, 11/8)

The most important issue in an election is sometimes, but seldom, the factor that actually determines the outcome of the election. That's what we saw happen in Virginia this week. Health was the top issue in the Virginia race, according to exit polls, but it was only one of many factors that drove the election. The bottom line: The election may have been more of a referendum on President Trump than health care — but the results in Virginia and in the Maine referendum on Medicaid expansion will still have a practical impact on what happens next, including the appetite for Affordable Care Act repeal and for cutting Medicaid to pay for tax cuts. (Drew Altman, 11/10)

This week Maine voted to become the 32nd state to expand Medicaid despite opposition by Gov. Paul LePage, who had vetoed five previous expansion bills passed by the state legislature and has now threatened to block the results of the ballot initiative. Unless Mr. LePage succeeds, about 80,000 more Mainers will be eligible for coverage, a victory in an unsettling year for health care in America. With the Affordable Care Act under constant threat from the Trump administration and out-of-pocket costs rising faster than wages, health care topped the list of the most important issues facing Americans this year. (Zak Ringelstein, 11/9)

But he eventually succumbed to that final straw that broke his back. Em was dead. And when I gave my best friend his last good-bye and spoke his eulogy, we all missed those days of doing what a patient needed, rather than what a bureaucrat wanted. We knew, if Em could speak, he might regret that phrase.“Joe, that’s just the way life is.” Em died. We lost him in a blizzard of records, finances, trivialities, computerized slowdowns with decreased productivity, and the fact that our patient/friends had now just become patients. For Em, you see, was the first letter of my beloved . . . Medicine. (Joseph P. Bark, 11/10)

Health care professionals generally have a respectful, sometimes even friendly, attitude toward law enforcement. We may feel we’re on the same team as the police when we’re treating victims of crime, and police may be called to protect us from people who seek to harm us in the hospital. Some health care professionals in emergency departments or intensive care units may have frequent interactions with police officers who are investigating alleged crimes. But the relationship may be profoundly tested when health care professionals refuse demands from law enforcement that conflict with what we understand to be our professional obligations. These conflicts may arise when law-enforcement officers prevent clinicians from having confidential discussions with patients, demand inappropriate restraints for patients that severely impede examination and treatment, or demand that health care personnel draw specimens from patients or retrieve evidence in an invasive manner from those who refuse or are unable to consent because they lack decision-making capacity due to delirium, confusion, or unconsciousness. (Arthur R. Derse, 11/8)

As a student in the 1980s, Sandra Suarez was president of the Brody Middle School “Just Say No” club. It was named for former First Lady Nancy Reagan’s admonition to reject drugs and alcohol. It made perfect sense to the young Cuban-American girl, who had an alcoholic father and had witnessed what she calls “some of the ugliest things that no child should have to see.” She was so keen to get far away that she chose a college in Washington state. Her father stopped drinking after she left. Rekha Basu, 11/9)

Last year, just weeks before the election, an article from a site called Mad World News began circulating around Facebook. The headline read “Before Applauding Hillary’s Abortion Remarks, Know the One Fact She Ignored.” In the article, the writer says she wants to expose Hillary Clinton’s lies about late-term abortions. She argues that a baby never needs to be aborted to save a mother’s life but doesn’t cite any sources or studies, and presents anecdotes and opinion as fact. Midway through the story, she shares an illustration of what she calls a “Partial-Birth Procedure” — a procedure banned in the United States. In it, she describes how a doctor “jams scissors into the baby’s skull” and how “the child’s brains are sucked out.” (Rossalyn Warren, 11/10)

The use of mobile communication technologies to improve the health of individuals and populations — dubbed “mobile health,” or “mHealth” — has grown dramatically since 2008, when the term mHealth became widely used. The excitement over the use of mHealth technology especially in low- and middle-income countries (LMICs) stems from the recognition that mobile phones have penetrated the market like no other technology. There are more than 5 billion wireless communication subscribers, and more than 70% of them are in LMICs1 (though the subscription rate in low-income countries is 60% overall, and much lower in rural areas). Moreover, commercial wireless signals reach 85% or more of the world’s population, extending much farther than the electrical grid. (Amira Roess, 11/8)