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The answer requires quite a bit of education, information and foresight as every other 1st world country has had a proven Universal health care system for decades that is lower cost with better outcomes than the USA health care system.US Spends More on Health Care Than Other High-Income Nations But Has Lower Life Expectancy, Worse HealthPeople such as myself fight for the ACA because it is the only form of Universal health care available to USA citizens under age 65. All citizens including yourself are winners because of this as the Biggest Cause of Personal Bankruptcies? Medical Bills.You are a winner under this system in the long run because when the tax-exempt health sharing program kicks you out or when the tax-exempt health sharing program you are in becomes bankrupt you will have access to Universal health care.Your tax-exempt health sharing program is not large enough to be financially stable and is likely not available to all citizens especially those with pre existing conditions. we need to take care of all citizens.Universal health care is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[3]We need all healthcare model that covers all citizens not just the ones that happen to be fortunate and well off.The ACA (Patient Protection and Affordable Care Act - Wikipedia) is not the optimal solution as the best solution is likely a Single-payer healthcare which is a proven economic model practiced in many 1st world countries. It is probably the best proven method of providing economically efficient Universal health care.Here are the wikipages describing how Universal health care - Wikipedia works in all countries around the world. The ACA is a decent start although it is time to improve it not throw it out going back to the 3rd world stone ages.Even Trump may now realize this inescapable fact as Here’s why Trump is already waffling on Obamacare.Universal health care - WikipediaUniversal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, usually refers to a health care system which provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.[2]Universal health care is not one-size-fits-all and does not imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered.[2]It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship.[3]The health policy framework is of central importance. Thus, in the development of universal health systems, it is appropriate to recognize "healthy public policy" (Health in All Policies) as the overarching policy framework, with public health, primary health care, and community services as the cross-cutting framework for all health and health-related services operating across the spectrum from primary prevention to long term care and end-stage conditions. Although that perspective is both logical and well grounded in the social ecological model, the reality is different in most settings, and there is room for improvement everywhere.[4]History[edit]The first move towards a national health insurance system was launched in Germany in 1883, with the Sickness Insurance Law. Industrial employers were mandated to provide injury and illness insurance for their low-wage workers, and the system was funded and administered by employees and employers through "sick funds", which were drawn from deductions in workers' wages and from employers' contributions. Other countries soon began to follow suit. In the United Kingdom, the National Insurance Act 1911 provided coverage for primary care (but not specialist or hospital care) for wage earners, covering about one third of the population. The Russian Empire established a similar system in 1912, and other industrialized countries began following suit. By the 1930s, similar systems existed in virtually all of Western and Central Europe. Japan introduced an employee health insurance law in 1927, expanding further upon it in 1935 and 1940. Following the Russian Revolution of 1917, the Soviet Union came close to a universal health care system. It established a fully public and centralized health care system in 1920.[5][6]However, it was not a truly universal system at that point, as rural residents were not http://covered.In New Zealand, a universal health care system was created in a series of steps, from 1939 to 1941.[7][8]In Australia, the state of Queensland introduced a free public hospital system in the 1940s.Following World War II, universal health care systems began to be set up around the world. On July 5, 1948, the United Kingdom launched its universal National Health Service. Universal health care was next introduced in the Nordic countries of Sweden (1955),[9]Iceland (1956),[10] Norway (1956),[11] Denmark (1961),[12] and Finland (1964).[13]Universal health insurance was then introduced in Japan (1961), and in Canada through stages, starting with the province of Saskatchewan in 1962, followed by the rest of Canada from 1968 to 1972.[7][14]The Soviet Union extended universal health care to its rural residents in 1969.[7][15]Italy introduced its Servizio Sanitario Nazionale (National Health Service) in 1978. Universal health insurance was implemented in Australia beginning with the Medibank system in 1975, which led to universal coverage under the Medicare system, established in 1984.From the 1970s to the 2000s, Southern and Western European countries began introducing universal coverage, most of them building upon previous health insurance programs to cover the whole population. For example, France built upon its 1928 national health insurance system, with subsequent legislation covering a larger and larger percentage of the population, until the remaining 1% of the population that was uninsured received coverage in 2000.[16][17]In addition, universal health coverage was introduced in some Asian countries, including South Korea (1989), Taiwan (1995), Israel (1995), and Thailand (2001).Following the collapse of the Soviet Union, Russia retained and reformed its universal health care system,[18] as did other former Soviet nations and Eastern bloc countries.Beyond the 1990s, many countries in Latin America, the Caribbean, Africa, and the Asia-Pacific region, including developing countries, took steps to bring their populations under universal health coverage, including China which has the largest universal health care system in the world.[19]A 2012 study examined progress being made by these countries, focusing on nine in particular: Ghana, Rwanda, Nigeria, Mali, Kenya, India, Indonesia, the Philippines, and Vietnam.[20][21]Funding models[edit]Universal health care in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (by direct or optional insurance) for services beyond those covered by the public system.Almost all European systems are financed through a mix of public and private contributions.[22]Most universal health care systems are funded primarily by tax revenue (like in Portugal[22] Spain, Denmark, and Sweden). Some nations, such as Germany and France[23] and Japan[24] employ a multipayer system in which health care is funded by private and public contributions. However, much of the non-government funding is by contributions by employers and employees to regulated non-profit sickness funds. Contributions are compulsory and defined according to law.A distinction is also made between municipal and national healthcare funding. For example, one model is that the bulk of the healthcare is funded by the municipality, speciality healthcare is provided and possibly funded by a larger entity, such as a municipal co-operation board or the state, and the medications are paid by a state agency.Universal health care systems are modestly redistributive. The progressivity of health care financing has limited implications for overall income inequality.[25]Compulsory insurance[edit]This is usually enforced via legislation requiring residents to purchase insurance, but sometimes the government provides the insurance. Sometimes, there may be a choice of multiple public and private funds providing a standard service (as in Germany) or sometimes just a single public fund (as in Canada). Healthcare in Switzerland and the US Patient Protection and Affordable Care Act are based on compulsory insurance.[26][27]In some European countries in which private insurance and universal health care coexist, such as Germany, Belgium, and the Netherlands, the problem of adverse selection is overcome by using a risk compensation pool to equalize, as far as possible, the risks between funds. Thus, a fund with a predominantly healthy, younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool. In this way, sickness funds compete on price, and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments. Funds are not allowed to pick and choose their policyholders or deny coverage, but they compete mainly on price and service. In some countries, the basic coverage level is set by the government and cannot be modified.[28]The Republic of Ireland at one time had a "community rating" system by VHI, effectively a single-payer or common risk pool. The government later opened VHI to competition but without a compensation pool. That resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market, which then made higher profits at VHI's expense. The government later reintroduced community rating by a pooling arrangement and at least one main major insurance company, BUPA, then withdrew from the Irish market.Among the potential solutions posited by economists are single-payer systems as well as other methods of ensuring that health insurance is universal, such as by requiring all citizens to purchase insurance or limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals.[29][30]Single payer[edit]Single-payer health care is a system in which the government, rather than private insurers, pays for all health care costs.[31]Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or own and employ healthcare resources and personnel (as was the case in England before of the Health and Social Care Act). "Single-payer" thus describes only the funding mechanism and refers to health care financed by a single public body from a single fund and does not specify the type of delivery or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.Tax-based financing[edit]In tax-based financing, individuals contribute to the provision of health services through various taxes. These are typically pooled across the whole population, unless local governments raise and retain tax revenues. Some countries (notably the United Kingdom, Canada, Ireland, Australia, New Zealand, Italy, Spain, Portugal, Greece and the Nordic countries) choose to fund health care directly from taxation alone. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.Social health insurance[edit]In social health insurance, contributions from workers, the self-employed, enterprises and government are pooled into a single or multiple funds on a compulsory basis. The funds typically contract with a mix of public and private providers for the provision of a specified benefit package. Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health. Within social health insurance, a number of functions may be executed by parastatal or non-governmental sickness funds or in a few cases by private health insurance companies.Private insurance[edit]In private health insurance, premiums are paid directly from employers, associations, individuals and families to insurance companies, which pool risks across their membership base. Private insurance includes policies sold by commercial for profit firms, non-profit companies, and community health insurers. Generally, private insurance is voluntary in contrast to social insurance programs, which tend to be compulsory.[32]In some countries with universal coverage, private insurance often excludes many health conditions that are expensive and the state health care system can provide. For example, in the United Kingdom, one of the largest private health care providers is BUPA, which has a long list of general exclusions even in its highest coverage policy,[33] most of which are routinely provided by the National Health Service. In the United States, dialysis treatment for end stage renal failure is generally paid for by government, not by the insurance industry. Those with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis paid through their insurance company, but those with end stage renal failure generally cannot buy Medicare Advantage plans.[34]The Planning Commission of India has also suggested that the country should embrace insurance to achieve universal health coverage.[35] General tax revenue is currently used to meet the essential health requirements of all people.Community-based health insurance[edit]A particular form of private health insurance that has often emerged if financial risk protection mechanisms have only a limited impact is community-based health insurance. Individual members of a specific community pay to a collective health fund, which they can draw from when they need of medical care. Contributions are not risk-related, and there is generally a high level of community involvement in the running of these plans.Implementation and comparisons[edit]Main article: Universal health coverage by countrySee also: Health care system and Health systems by countryHealth spending per capita, in US$ purchasing power parity-adjusted, among various OECD countriesUniversal health care systems vary according to the degree of government involvement in providing care and/or health insurance. In some countries, such as the UK, Spain, Italy, Australia and the Nordic countries, the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights, not on the purchase of insurance. Others have a much more pluralistic delivery system, based on obligatory health with contributory insurance rates related to salaries or income and usually funded by employers and beneficiaries jointly.Sometimes, the health funds are derived from a mixture of insurance premiums, salary related mandatory contributions by employees and/or employers to regulated sickness funds, and by government taxes. These insurance based systems tend to reimburse private or public medical providers, often at heavily regulated rates, through mutual or publicly owned medical insurers. A few countries, such as the Netherlands and Switzerland, operate via privately owned but heavily regulated private insurers, which are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance.Universal health care is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually, some costs are borne by the patient at the time of consumption, but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others, tax revenues are used either to fund insurance for the very poor or for those needing long-term chronic care.The United Kingdom National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the United States), and their relative costs and key health outcomes.[36]A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004.[37]In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.Single-payer healthcareSingle-payer healthcare is a system in which the state, rather than private insurers, pays for all healthcare costs.[1]Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the United Kingdom).The term "single-payer" thus describes the funding mechanism, referring to healthcare financed by a single public body from a single fund, not the type of delivery or for whom physicians work. The British system is technically not single payer, as it consists of a number of financially and legally autonomous trusts.The actual funding of a "single payer" system comes from all or a portion of the covered population. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.Description[edit]Single-payer health insurance collects all medical fees and then pays for all services, by a single government (or government-related) source.[2]In wealthy nations, that kind of publicly managed insurance is typically extended to all citizens and legal residents. Examples include the United Kingdom's National Health Service, Australia's Medicare, Canada's Medicare, and Taiwan's National Health Insurance.The standard usage of the term "single-payer healthcare" refers to health insurance, as opposed to healthcare delivery, operating as a public service and offered to citizens and legal residents towards providing nearly universal or universal healthcare. The fund can be managed by the government directly or as a publicly owned and regulated agency.[2]Some writers describe publicly administered systems as "single-payer plans". Some writers have described any system of healthcare which intends to cover the entire population, such as voucher plans, as "single-payer plans",[3] but that is uncommon.Countries and regions[edit]Many nations worldwide have single-payer health insurance programs. These programs generally provide some form of universal healthcare, which are implemented in a variety of ways. In some cases doctors are employed, and hospitals run by, the government such as in the United Kingdom[4] or Spain.[5]Alternatively the government may purchase healthcare services from outside organizations, such as the approach taken in Canada.Australia[edit]Healthcare in Australia is provided by both private and government institutions. Medicare is the publicly funded universal health care venture in Australia. It was instituted in 1984 and coexists with a private health system. Medicare is funded partly by a 2% income taxlevy[6](with exceptions for low-income earners), but mostly out of general revenue. An additional levy of 1% is imposed on high-income earners without private health insurance. As well as Medicare, there is a separate Pharmaceutical Benefits Scheme that considerably subsidises a range of prescription medications. The Minister for Health, currently Sussan Ley, administers national health policy, elements of which (such as the operation of hospitals) are overseen by individual states.Canada[edit]See also: Canadian and American health care systems compared and Medicare (Canada)Healthcare in Canada is delivered through a publicly funded healthcare system, which is mostly free at the point of use and has most services provided by private entities.[7]It is guided by the provisions of the Canada Health Act of 1984.[8]The government assures the quality of care through federal standards. The government does not participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and his or her physician. Canada's provincially based Medicare systems are cost-effective partly because of their administrative simplicity. In each province each doctor handles the insurance claim against the provincial insurer. There is no need for the person who accesses healthcare to be involved in billing and reclaim. Private insurance represents a minimal part of the overall system.Competitive practices such as advertising are kept to a minimum, thus maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, except in British Columbia, the only province to impose a fixed monthly premium which is waived or reduced for those on low incomes.[9]There are no deductibles on basic health care and co-pays are extremely low or non-existent (supplemental insurance such as Fair Pharmacare may have deductibles, depending on income). A health card is issued by the Provincial Ministry of Health to each individual who enrolls for the program and everyone receives the same level of care.[10]There is no need for a variety of plans because virtually all essential basic care is covered, including maternity and infertility problems. Depending on the province, dental and vision care may not be covered but are often insured by employers through private companies. In some provinces, private supplemental plans are available for those who desire private rooms if they are hospitalized. Cosmetic surgery and some forms of elective surgery are not considered essential care and are generally not covered. These can be paid out-of-pocket or through private insurers. Health coverage is not affected by loss or change of jobs, as long as premiums are up to date, and there are no lifetime limits or exclusions for pre-existing conditions.Pharmaceutical medications are covered by public funds for the elderly or indigent,[11]or through employment-based private insurance. Drug prices are negotiated with suppliers by the federal government to control costs. Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counseled to see a specialist, a referral can be made by a GP. Canadians do wait for some treatments and diagnostic services. Survey data shows that the median wait time to see a special physician is a little over four weeks with 89.5% waiting less than three months. The median wait time for diagnostic services such as MRI and CAT scans[12] is two weeks, with 86.4% waiting less than three months.[13]The median wait time for surgery is four weeks, with 82.2% waiting less than three months.[14]Spain[edit]Building upon less structured foundations, in 1963 the existence of a single-payer healthcare system in Spain was established by the Spanish government.[15]The system was sustained by contributions from workers, and covered them and their dependents.[16]The universality of the system was established later in 1986. At the same time, management of public healthcare was delegated to the different autonomous communities in the country.[17]While previously this was not the case, in 1997 it was established that public authorities can delegate management of publicly funded healthcare to private companies.[18]Additionally, in parallel to the single-payer healthcare system there are private insurers, which provide coverage for some private doctors and hospitals. Employers will sometimes offer private health insurance as a benefit,[19] with 14.8% of the Spanish population being covered under private health insurance in 2013.[20]In 2000, the Spanish healthcare system was rated by the World Health Organization as the 7th best in the world.Taiwan[edit]Healthcare in Taiwan is administrated by the Department of Health of the Executive Yuan. As with other developed economies, Taiwanese people are well-nourished but face such health problems as chronic obesity and heart disease.[21]In 2002 Taiwan had nearly 1.6 physicians and 5.9 hospital beds per 1,000 population.[21]In 2002, there were a total of 36 hospitals and 2,601 clinics in the country. Per capita health expenditures totaled US$752 in 2000.[21]Health expenditures constituted 5.8 percent of the gross domestic product (GDP) in 2001 (or $951 US in 2009[22]); 64.9 percent of the expenditures were from public funds.[21]Overall life expectancy in 2009 was 78 years.[23]The current healthcare system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health-care funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[24]NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many healthcare providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.United Kingdom[edit]Healthcare in the United Kingdom is a devolved matter, meaning England, Northern Ireland, Scotland and Wales each have their own systems of private and publicly funded healthcare, generally referred to as the National Health Service (NHS). Each country having different policies and priorities has resulted in a variety of differences existing between the systems.[25][26]That said, each country provides public healthcare to all UK permanent residents that is free at the point of use, being paid for from general taxation. In addition, each also has a private sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer, though provision can be restricted for those with conditions such as AIDS/HIV.[27]The individual systems are:England: National Health ServiceNorthern Ireland: Health and Social Care in Northern Ireland (HSCNI)Scotland: NHS ScotlandWales: NHS WalesIn England, funding from general taxation is channeled through NHS England, which is responsible for commissioning mainly specialist services and primary care, and Clinical Commissioning Groups (CCGs), which hold 60% of the budget and are responsible for commissioning health services for their local populations.[28]These commissioning bodies do not provide services themselves directly, but procure these from NHS Trusts and Foundation Trusts, as well as private, voluntary and social enterprise sector providers.[29]United States[edit]A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All") but none has achieved more than 20% congressional co-sponsorship.Advocates argue that preventive healthcare expenditures can save several hundreds of billions of dollars per year because publicly funded universal healthcare would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, would be spared administrative costs, and inequities between employers would be reduced. Advocates also argue that single payer could benefit from a more fluid economy with increasing economic growth, aggregate demand, corporate profit, and quality of life.[30][31][32]Also, for example, cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal.[33][34]Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventive health care,[35] although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventive care is more expensive due to increased utilization.[36]Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventive care and the elimination of insurance company overhead and hospital billing costs.[37]An analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year.[38]The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.[39]Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, are seen as possible routes to enacting single-payer on the federal level.[40][41]In December 2014, Vermont cancelled its plan for single payer healthcare.[42]National policies and proposals[edit]Medicare in the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with End-Stage Renal Disease.[43]Government is increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on individuals' medical care in 2004.[44]However, studies have shown that the publicly administered share of health spending in the U.S. may be closer to 60% as of 2002.[45]According to Princeton University health economist Uwe Reinhardt, U.S. Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP) represent "forms of 'social insurance' coupled with a largely private health-care delivery system" rather than forms of "socialized medicine." In contrast, he describes the Veterans Administration healthcare system as a pure form of socialized medicine because it is "owned, operated and financed by government."[46]In a peer-reviewed paper published in the Annals of Internal Medicine, researchers of the RAND Corporation reported that the quality of care received by Veterans Administration patients scored significantly higher overall than did comparable metrics for patients currently using United States Medicare.[47]The United States National Health Care Act, is a perennial piece of legislation introduced in the United States House of Representatives by Representative John Conyers (D-MI) every year since 2002.[48]The act would establish a universal single-payer health care system in the United States, the rough equivalent of Canada's Medicare, the United Kingdom's National Health Service, and Taiwan's Bureau of National Health Insurance, among other examples. Under a single payer system, all medical care would be paid for by the Government of the United States, ending the need for private health insurance and premiums, and probably recasting private insurance companies as providing purely supplemental coverage, to be used when non-essential care is sought. The bill was first introduced in 2002,[48] and has been reintroduced in each Congress since. During the 2009 health care debates over the bill that became the Patient Protection and Affordable Care Act, H.R. 676 was expected to be debated and voted upon by the House in September 2009,[49] but was never debated.[50]The Congressional Budget Office and related government agencies scored the cost of a single payer health care system several times since 1991. The General Accounting Office published a report in 1991 noting that "[I]f the US were to shift to a system of universal coverage and a single payer, as in Canada, the savings in administrative costs [10 percent of health spending] would be more than enough to offset the expense of universal coverage.”[51]The CBO scored the cost in 1991, noting that "the population that is currently uninsured could be covered without dramatically increasing national spending on health" and that "all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured.[52]A CBO report in 1993 stated that "[t]he net cost of achieving universal insurance coverage under this single payer system would be negative" in part because "consumer payments for health would fall by $1,118 per capita, but taxes would have to increase by $1,261 per capita" in order to pay for the plan.[53]A July 1993 scoring also resulted in positive outcomes, with the CBO stating that, "[a]s the program was phased in, the administrative savings from switching to a single-payer system would offset much of the increased demand for health care services. Later, the cap on the growth of the national health budget would hold the rate of growth of spending below the baseline."[54]The CBO also scored Sen. Paul Wellstone's American Health and Security Act of 1993 in December 1993, finding that "by year five (and in subsequent years) the new system would cost less than baseline."[55]A 2014 study published in the journal BMC Medical Services Research by James Kahn, etal, found that the actual administrative burden of health care in the United States was 27.4% of all national health expenditures. The study examined both direct costs charged by insurers for profit, administration and marketing but also the indirect burden placed on health care providers like hospitals, nursing homes and doctors for costs they incurred in working with private health insurers including contract negotiations, financial and clinical record-keeping (variable and idiosyncratic for each payer). Kahn, et al. estimate that the added cost for the private insurer health system in the US was about $471 billion in 2012 compared to a single payer system like Canada's. This represents just over 20% of the total national healthcare expenditure in 2012. Kahn asserts that this excess administrative cost will increase under the Affordable Care Act with its reliance on the provision of health coverage through a multi-payer system.[56]State proposals[edit]Several single-payer state referendums and bills from state legislatures have been proposed, but, with the exception of Vermont,[57] all have failed. In December 2014, Vermont canceled its plan for single payer health care.[42]California[edit]California attempted passage of a single-payer bill as early as 1994,[58]and the first successful passages of legislation through the California State Legislature, SB 840 or "The California Universal Healthcare Act" (authored by Sheila Kuehl), occurred in 2006 and again in 2008.[59]Both times, Governor Arnold Schwarzenegger vetoed the bill.[60]State Senator Mark Leno has reintroduced the bill in each legislative session since.[61]Colorado[edit]Colorado Amendment 69, will have a ballot proposal in November 2016 to vote on a single payer healthcare system funded by a 10% payroll tax split 2:1 between employers and employees. This would replace the private health insurance premiums currently paid by employees and companies.[62]Hawaii[edit]In 2009, the Hawaii state legislature passed a single-payer healthcare bill that was vetoed by Republican Governor Linda Lingle. While the veto was overridden by the legislature, the bill was not implemented.[63]Illinois[edit]In 2007, the Health Care for All Illinois Act was introduced and the Illinois House of Representatives' Health Availability Access Committee passed the single-payer bill favorably out of committee by an 8–4 vote. The legislation was eventually referred back to the House rules committee and not taken up again during that session.[64]Massachusetts[edit]Massachusetts had passed a universal healthcare program in 1986, but budget constraints and partisan control of the legislature resulted in its repeal before the legislation could be enacted.[65]Question 4, a nonbinding referendum, was on the ballot in 14 state districts in November 2010, asking voters, "[S]hall the representative from this district be instructed to support legislation that would establish healthcare as a human right regardless of age, state of health or employment status, by creating a single payer health insurance system like Medicare that is comprehensive, cost effective, and publicly provided to all residents of Massachusetts?" The ballot question passed in all 14 districts that offered the question.[66][67]Minnesota[edit]The Minnesota Health Act, which would establish a statewide single payer health plan, has been presented to the Minnesota legislature regularly since 2009. The bill was passed out of both the Senate Health Housing and Family Security Committee[68] and the Senate Commerce and Consumer Protection Committee[69] in 2009, but the House version was ultimately tabled.[70]In 2010, the bill passed the Senate Judiciary Committee on a voice vote[71] as well as the House Health Care & Human Services Policy and Oversight Committee.[72]In 2011, the bill was introduced as a two-year bill in both the Senate[73] and House,[74] but did not progress. It has been introduced again in the 2013 session in both chambers.[75][76]Montana[edit]In September 2011, Governor Brian Schweitzer announced his intention to seek a waiver from the federal government allowing Montana to set up a single payer healthcare system.[77]Governor Schweitzer was unable to implement single-payer health care in Montana, but did make moves to open government-run clinics[78] and, in his final budget as governor, increased coverage for lower-income Montana residents.[79]New York[edit]New York State has been attempting passage of the New York Health Act, which would establish a statewide single-payer health plan, since 1992. The New York Health Act has passed the Assembly twice, once in 1992 and again in 2015, but has failed to advance through the Senate after referrals to the Health Committee. On both occasions, the legislation passed the Assembly by an almost two-to-one ratio of support.[80]Oregon[edit]The state of Oregon attempted to pass single payer healthcare via Oregon Ballot Measure 23 in 2002, and the measure was rejected by a significant majority.[81]Previous bills, including the Affordable Health Care for All Oregon Act, have been introduced in the legislature but have never left committee. The Affordable Health Care Act may be reintroduced in the 2013 session.[82]Pennsylvania[edit]The Family Business and Healthcare Security Act has been introduced in the Pennsylvania legislature numerous times, but has never been able to pass.[83][84][85]Vermont[edit]In December 2014, Vermont canceled its plan for single payer healthcare.[42]Vermont passed legislation in 2011 creating Green Mountain Care.[86]When Governor Peter Shumlin signed the bill into law, Vermont became the first state to functionally have a single payer health care system.[87]While the bill is considered a single-payer bill, private insurers can continue to operate in the state indefinitely, meaning it does not fit the strict definition of single-payer. Representative Mark Larson, the initial sponsor of the bill, has described Green Mountain Care's provisions "as close as we can get [to single-payer] at the state level."[88][89]Vermont abandoned the plan in 2014, citing costs and tax increases as too high to implement.[90]Public opinion[edit]Advocates for single payer point to support in polls, although the polling is mixed depending on how the question is asked.[91]Polls from Harvard University in 1988,[92] the Los Angeles Times in 1990,[93] and the Wall Street Journal in 1991[94] all showed strong support for a health care system comparable to the system in Canada. More recently, however, polling support has declined.[91][95]A 2007 Yahoo/AP poll showed a majority of respondents considered themselves supporters of "single-payer health care,"[96] and a plurality of respondents in a 2009 poll for Time Magazine showed support for "a national single-payer plan similar to Medicare for all."[97]Polls by Rasmussen Reports in 2011[98] and 2012[99] showed pluralities opposed to single payer health care.A 2001 article in the public health journal Health Affairs studied fifty years of American public opinion of various health care plans and concluded that, while there appears to be general support of a "national health care plan," poll respondents "remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan."[95]Politifact rated a statement by Michael Moore "false" when he stated that "[t]he majority actually want single-payer health care." According to Politifact, responses on these polls largely depend on the wording. For example, people respond more favorably when they are asked if they want a system "like Medicare."[91]Advocacy groups[edit]This section needs to be updated. Please update this article to reflect recent events or newly available information. (February 2014)Physicians for a National Health Program[100] the American Medical Student Association[101] and the California Nurses Association[102] are among advocacy groups that have called for the introduction of a single payer healthcare program in the United States. A study published in the Annals of Internal Medicine found that 59% of physicians "supported legislation to establish national health insurance" while 9% were neutral on the topic, and 32% opposed it.[103]Universal health coverage by countryFrom Wikipedia, the free encyclopediaSee also: Health systems by country 58 countries with universal health care in 2009.[1]58 countries with legislation mandating universal health care, along with >90% health insurance coverage, and >90% skilled birth attendance.Main article: Universal health careUniversal health coverage is a broad concept that has been implemented in several ways. The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards. Most implement universal health care through legislation, regulation and taxation. Legislation and regulation direct what care must be provided, to whom, and on what basis. Usually some costs are borne by the patient at the time of consumption but the bulk of costs come from a combination of compulsory insurance and tax revenues. Some programs are paid for entirely out of tax revenues. In others tax revenues are used either to fund insurance for the very poor or for those needing long term chronic care. The UK government's National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries, nine universal systems against one non-universal system (the U.S.), and their relative costs and key health outcomes.[2]A wider international comparison of 16 countries, each with universal health care, was published by the World Health Organization in 2004[3]In some cases, government involvement also includes directly managing the health care system, but many countries use mixed public-private systems to deliver universal health care.The UN has adopted a resolution on universal health care. It may be the next stage after the Millennium Development Goals.[4]Africa[edit]Algeria[edit]Algeria operates a public healthcare system. A network of hospitals, clinics, and dispensaries provide treatment to the population, with the Social Security system funding health services, although many people must still cover part of their costs due to the rates paid by the Social Security system unchanged since 1987. The poor are generally entitled to health services free of charge, while the wealthy pay for treatment according to a sliding scale.[5][6]Botswana[edit]Botswana operates a system of public medical centers, with 98% of health facilities in the country run by the government. All citizens are entitled to be treated in public facilities free of charge, though a nominal fee of $70 is typically charged for public health services except for sexual reproductive health services and antiretroviral therapy services, which are free.[7]Burkina Faso[edit]Burkina Faso operates a scheme called Universal Health Insurance (AMU) which provides universal healthcare to citizens. It is administered by two separate bodies, one for civilians and the other for the armed forces.[8]Egypt[edit]Egypt operates a system of public hospitals and clinics through the Ministry of Health. Egyptian citizens can receive treatment at these facilities free of charge. However, those Egyptians who can afford it prefer to pay out of pocket for private healthcare.[9]Ghana[edit]Ghana operates the National Health Insurance Scheme to provide citizens with health insurance. The level of premiums citizens must pay varies according to their level of income. Most medical facilities are run directly by the Ministry of Health or Ghana Health Service.[10]Mauritius[edit]The Government of Mauritius operates a system of medical facilities that provide treatment to citizens free of charge.[11]Morocco[edit]Morocco operates a public health sector run by the government that operates 85% of the country's hospital beds. It deals mainly with the poor and rural populations, who cannot afford private healthcare. In addition, there is a non-profit health sector operated by the National Social Security Fund which covers 16% of the population. There is also a private sector for those who can afford it.[12]Rwanda[edit]Rwanda operates a system of universal health insurance through the Ministry of Health called Mutuelle de Santé (Mutual Health), a system of community-based insurance where people pay premiums based on their income level into local health insurance funds, with the wealthiest paying the highest premiums and required to cover a small percentage of their medical expenses, while those at the lowest income levels are exempt from paying premiums and can still utilize the services of their local health fund. In 2012, this system insured all but 4% of the population.[13]South Africa[edit]South Africa has a public healthcare system that provides services to the vast majority of the population, though it is chronically underfunded and understaffed, and a private system that is far better equipped, which covers the wealthier sectors of society.[14]Tunisia[edit]Tunisia operates a public healthcare system under the National Health Insurance Fund (Caisse Nationale d'Assurance Maladie). All Tunisian citizens and residents can receive treatment in state-run hospitals and clinics free of charge.[15]Asia[edit]Countries that provide public healthcare in Asia include Bhutan,[16]Bahrain,[17]China, Hong Kong, India, Iran,[18]Israel[19](see below), Jordan,[20]Kazakhstan,[21]Macau (see below), Malaysia,[22]Mongolia,[23]Oman,[24][25]Singapore, Sri Lanka,[26]Syria,[27]Taiwan (R.O.C.)[28](see below), Tajikistan,[29]Thailand (see below), Turkey,[30]and Turkmenistan[31]have universal health care.Bhutan[edit]The Royal Government of Bhutan maintains a policy of free and universal access to primary health care. As hospital facilities in the country are limited, patients with diseases that cannot be treated in Bhutan, such as cancer, are normally referred to hospitals in India for treatment. Such referral treatment is also carried out at the cost of the Royal Government.[32]Hong Kong[edit]Hong Kong has early health education, professional health services, and well-developed health care and medication system. The life expectancy is 84 for females and 78 for males,[33]which is the second highest in the world, and 2.94 infant mortality rate, the fourth lowest in the world.[34][35]There are two medical schools in Hong Kong, and several schools offering courses in traditional Chinese medicine. The Hospital Authority is a statutory body that operates and manages all public hospitals. Hong Kong has high standards of medical practice. It has contributed to the development of liver transplantation, being the first in the world to carry out an adult to adult live donor liver transplant in 1993.[36]India[edit]India's healthcare system is dominated by the private sector, although there are various public healthcare systems like Rajiv Gandhi Jeevandayee Arogya Yojana in Maharashtra that provides free healthcare to those below the poverty line.[37][38]Currently, the majority of Indian citizens do not have health insurance, and must pay out of pocket for treatment. There are government hospitals that provide treatment at taxpayer expense. Some essential drugs are offered free of charge in these hospitals.An outpatient card at AIIMS costs a one-time fee of 10 rupees (around 20 cents U.S.) and thereafter outpatient medical advice is free. In-hospital treatment costs depend on the financial condition of the patient and the facilities utilized, but are usually much less than the private sector. For instance, a patient is waived treatment costs if their income is below the poverty line. However, getting treatment at high quality government hospitals is very tough due to the high number of people needing healthcare and the lack of sufficient facilities.Primary health care is provided by city and district hospitals and rural primary health centres (PHCs). These hospitals provide treatment free of cost, but only if they are functional. Primary care is focused on immunization, prevention of malnutrition, pregnancy, child birth, postnatal care, and treatment of common illnesses.Patients who receive specialized care or have complicated illnesses are referred to secondary (often located in district and taluk headquarters) and tertiary care hospitals (located in district and state headquarters or those that are teaching hospitals).Now organizations like Hindustan Latex Family Planning Promotional Trust and other private organizations have started creating hospitals and clinics in India, which also provide free or subsidized health care and subsidized insurance plans.The government-run healthcare suffers from a lack of hygiene; the rich avoid the government hospitals and go to private hospitals. With the advent of privatized healthcare, this situation has changed. India now has medical tourism for people from other countries while its own poor find high-quality healthcare either inaccessible or unaffordable.The current Indian government is planning to unveil a national universal healthcare system called the National Health Assurance Mission, which will provide all Indian citizens with insurance coverage for serious illnesses, and free drugs and diagnostic treatments.[39]Israel[edit]Health care in Israel as a percentage of GDPIsrael has a system of universal healthcare as set out by the 1995 National Health Insurance Law. The state is responsible for providing health services to all residents of the country, who can register with one of the four national health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, preventive dental care for children, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.[40]In Israel, the National Health Insurance Law (or National Health Insurance Act) is the legal framework which enables and facilitates basic, compulsory universal health care. The Law was put into effect by the Knesset on January 1, 1995, and was based on recommendations put forward by a National Committee of Inquiry headed by Shoshana Netanyahu which examined restructuring the health care system in Israel in the late 1980s. Prior to the law's passage over 90% of the population was already covered by voluntarily belonging to one of four nationwide, not-for-profit sickness funds which operated some of their own medical facilities and were funded in part by employers and the government and in part by the insured by levies which varied according to income. However, there were three problems associated with this arrangement. First, membership in the largest fund, Clalit, required one to belong to the Histadrut labor organization, even if a person did not wish to (or could not) have such an affiliation while other funds restricted entry to new members based on age, pre-existing conditions or other factors. Second, different funds provided different levels of benefit coverage or services to their members and lastly was the issue mentioned above whereby a certain percentage of the population, albeit a small one, did not have health insurance coverage at all.Before the law went into effect, all the funds collected premiums directly from members. However, upon passage of the law, a new progressive national health insurance tax was levied through Israel's social security agency which then re-distributes the proceeds to the sickness funds based on their membership and its demographic makeup. This ensured that all citizens would now have health coverage. While membership in one of the funds now became compulsory for all, free choice was introduced into movement of members between funds (a change is allowed once every six months), effectively making the various sickness funds compete equally for members among the populace. Annually, a committee appointed by the ministry of health publishes a "basket" or uniform package of medical services and prescription formulary which all funds must provide as a minimum service to all their members. Achieving this level of equality ensured that all citizens are guaranteed to receive basic healthcare regardless of their fund affiliation which was one of the principal aims of the law. An appeals process was put in place to handle rejection of treatments and procedures by the funds and evaluating cases falling outside the "basket" of services or prescription formulary.While the law is generally considered a success and Israeli citizens enjoy a high standard of medical care comparatively, with more competition having been introduced into the field of health care in the country, and order having been brought into what was once a somewhat disorganized system, the law nevertheless does have its critics. First and foremost among the criticisms raised is that the "basket" may not provide enough coverage. To partly address this issue, the HMOs and insurance companies began offering additional "supplementary" insurance to cover certain additional services not included in the basket. However, since this insurance is optional (though usually very modestly priced, costing the equivalent of about US$10 to $20 a month), critics argue that it goes against the spirit of the new law which stressed equality among all citizens with respect to healthcare. Another criticism is that in order to provide universal coverage to all, the tax income base amount (the maximum amount of yearly earnings that are subject to the tax) was set rather high, causing many high-income taxpayers to see the amount they pay for their health premiums (now health tax) skyrocket. Finally, some complain about the constantly rising costs of copayments for certain services.Macau[edit]Macau offers universally accessible single-payer system funded by taxes. Health care is provided by the Bureau for Health.People's Republic of China[edit]Since the founding of the People's Republic of China, the goal of health care programs has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources.China is undertaking a reform on its health care system, which was largely privatized in the 1990s. The New Rural Co-operative Medical Care System (NRCMCS), is a new 2005 initiative to overhaul the healthcare system, particularly intended to make it more affordable for the rural poor. Under the NRCMCS, the annual cost of medical coverage is 50 yuan (US$7) per person. Of that, 20 yuan is paid in by the central government, 20 yuan by the provincial government and a contribution of 10 yuan is made by the patient. As of September 2007, around 80% of the whole rural population of China had signed up (about 685 million people). The system is tiered, depending on the location. If patients go to a small hospital or clinic in their local town, the scheme will cover from 70–80% of their bill. If they go to a county one, the percentage of the cost being covered falls to about 60%. And if they need specialist help in a large modern city hospital, they have to bear most of the cost themselves, the scheme would cover about 30% of the bill.[41]On January 21, 2009, the Chinese government announced that a total of 850 billion yuan (US$127.5 billion) will be provided between 2009 and 2011 in order to improve the existing health care system.[42]At the end of 2008, the government published its reform plan clarifying government's responsibility by saying that it would play a dominant role in providing public health and basic medical service. It declared "Both central and local governments should increase health funding. The percentage of government's input in total health expenditure should be increased gradually so that the financial burden of individuals can be reduced," The plan listed public health, rural areas, city community health services and basic medical insurance as four key areas for government investment. It also promised to tighten government control over medical fees in public hospitals and to set up a "basic medicine system" to quell public complaints of rising drug costs.[43]The plan was passed by the Chinese Cabinet in January 2009. The long-awaited medical reform plan promised to spend 850 billion yuan by 2011 to provide universal medical service and that measures would be taken to provide basic medical security to all Chinese.[44]Singapore[edit]Singapore has a universal health care system where government ensures affordability, largely through compulsory savings and price controls, while the private sector provides most care. Overall spending on health care amounts to only 3% of annual GDP. Of that, 66% comes from private sources.[45]Singapore currently has the second lowest infant mortality rate in the world and among the highest life expectancies from birth, according to the World Health Organization.[46]Singapore has "one of the most successful healthcare systems in the world, in terms of both efficiency in financing and the results achieved in community health outcomes," according to an analysis by global consulting firm Watson Wyatt.[47]Singapore's system uses a combination of compulsory savings from payroll deductions (funded by both employers and workers) a nationalized health insurance plan, and government subsidies, as well as "actively regulating the supply and prices of healthcare services in the country" to keep costs in check; the specific features have been described as potentially a "very difficult system to replicate in many other countries." Many Singaporeans also have supplemental private health insurance (often provided by employers) for services not covered by the government's programs.[47]Taiwan[edit]The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health care dollars. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[48]NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers.NHI delivers universal coverage offered by a government-run insurer. The working population pays premiums split with their employers, others pay a flat rate with government help and the poor or veterans are fully subsidized.[49]Under this model, citizens have free range to choose hospitals and physicians without using a gatekeeper and do not have to worry about waiting lists. NHI offers a comprehensive benefit package that covers preventive medical services, prescription drugs, dentalservices, Chinese medicine, home nurse visits and many more. Since NHI, the previously uninsured have increased their usage of medical services. Most preventive services are free such as annual checkups and maternal and child care. Regular office visits have co-payments as low as US $5 per visit. Co-payments are fixed and unvaried by the person's income.[50]Thailand[edit]Thailand introduced universal coverage reforms in 2001, becoming one of only a handful of lower-middle income countries to do so at the time. Means-tested health care for low income households was replaced by a new and more comprehensive insurance scheme, originally known as the 30 baht project, in line with the small co-payment charged for treatment. People joining the scheme receive a gold card which allows them to access services in their health district, and, if necessary, be referred for specialist treatment elsewhere. The bulk of finance comes from public revenues, with funding allocated to Contracting Units for Primary Care annually on a population basis. According to the WHO, 65% of Thailand's health care expenditure in 2004 came from the government, 35% was from private sources.[45]Although the reforms have received a good deal of critical comment, they have proved popular with poorer Thais, especially in rural areas, and survived the change of government after the 2006 military coup. The then Public Health Minister, Mongkol Na Songkhla, abolished the 30 baht co-payment and made the UC scheme free. It is not yet clear whether the scheme will be modified further under the coalition government that came to power in January 2008.[51][52][53]Europe[edit]Virtually all of Europe has either publicly sponsored and regulated universal health care or publicly provided universal healthcare. The public plans in some countries provide basic or "sick" coverage only, with their citizens being able to purchase supplemental insurance for additional coverage. Countries with universal health care include Austria, Belarus,[54]Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, Moldova,[55]the Netherlands, Norway, Portugal,[56]Romania, Russia, Serbia, Spain, Sweden, Switzerland, Ukraine,[57]and the United Kingdom.[58]Austria[edit]Healthcare in Austria is universal for residents of Austria as well as those from other EU countries.[59]Austria has a two-tier health care system in which many individuals receive publicly funded care; they also have the option to purchase supplementary private health insurance.Croatia[edit]Croatia has a universal health care system that provides high quality medical services and is coordinated by the Ministry of Health. The population is covered by a basic health insurance plan provided by statute and optional insurance and administered by the Croatian Health Insurance Fund. In 2012, annual compulsory healthcare related expenditures reached 21.0 billion kunas (c. 2.8 billion euro). There are hundreds of healthcare institutions in Croatia, including 79 hospitals and clinics with 25,285 beds, caring for more than 760 thousand patients per year, 5,792 private practice offices and 79 emergency medical service units.Czech Republic[edit]Czech Republic has a universal public health system paid largely from taxation. Private health care systems do co-exist freely alongside public ones, sometimes offering better quality or faster service. Almost all medical services are covered by health insurance and insurance companies, though certain services such as prescription drugs or vision and dental care are only covered partially.Denmark[edit]Denmark has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Primary care is provided by a general practitioner service run by private doctors contracting with the local municipalities with payment on a mixed per capita and fee for service basis. Most hospitals are run by the municipalities (only 1% of hospital beds are in the private sector).Finland[edit]In Finland, public medical services at clinics and hospitals are run by the municipalities (local government) and are funded 76% by taxation, 20% by patients through access charges, and 4% by others. Private provision is mainly in the primary care sector. There are a few private hospitals.[60]The main hospitals are either municipally owned (funded from local taxes) or run by the medical teaching universities (funded jointly by the municipalities and the national government). According to a survey published by the European Commission in 2000, Finland's is in the top 4 of EU countries in terms of satisfaction with their hospital care system: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[61]Finnish health care expenditures are below the European average.[62]The private medical sector accounts for about 14 percent of total health care spending. Only 8% of doctors choose to work in private practice, and some of these also choose to do some work in the public sector.Taxation funding is partly local and partly nationally based. The national social insurance institution KELA reimburses part of patients prescription costs and makes a contribution towards private medical costs (including dentistry) if they choose to be treated in the private sector rather than the public sector. Patient access charges are subject to annual caps. For example, GP visits cost €11 per visit with annual €33 cap; hospital outpatient treatment €22 per visit; a hospital stay, including food, medical care and medicines €26 per 24 hours, or €12 if in a psychiatric hospital. After a patient has spent €590 per year on public medical services (including prescription drugs), all treatment and medications thereafter in that year are free.Finland has a highly decentralized three-level public system of health care and alongside this, a much smaller private health-care system.[63]Overall, the municipalities (funded by taxation, local and national) meet about two thirds of all medical-care costs, with the remaining one third paid by the national insurance system (nationally funded), and by private finance (either employer-funded or met by patients themselves).[63]Private inpatient care forms about 3–4% of all inpatient care.[63]In 1999 only 17 per cent of total funding for health care came from insurance, comprising 14.9% statutory (government) insurance and 2.1% private health insurance. Spectacles are not publicly subsidized at all, although dentistry is available as a municipal service or can be obtained privately with partial reimbursement from the state.[63]The government announced in 2009 that Kela would re-imburse the cost of private dental-hygiene work, starting in 2010.[64]The percentage of total health expenditure financed by taxation in Finland (78%)[65]is above the OECD average and similar to the levels seen in Germany (77%) and France (80%) but below the level seen in the UK (87%). The quality of service in Finnish health care, as measured by patient satisfaction, is excellent. According to a survey published by the European Commission in 2000, Finland has one of the highest ratings of patient satisfaction with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.[66]There are caps on total medical expenses that are met out-of-pocket for drugs and hospital treatments. The National Insurance system pays all necessary costs over these caps. Public spending on health care in 2006 was 13.6 billion euros (equivalent to US$338 per person per month). The increase over 2005 at 8.2 per cent was below the OECD average of 9 percent. Household budgets directly met 18.7 per cent of all health-care costs.[67]France[edit]France has a system of universal health care largely financed by government through a system of national health insurance. It is consistently ranked as one of the best in the world.[68]Germany[edit]Germany has the world's oldest national social health insurance system,[69][70][71]with origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.[72][73]The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.[74]Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physician's associations and sickness funds. Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[75]The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.[76]Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[77][78]The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[79]Greece[edit]The Greek healthcare system provides high quality medical services to insured citizens and is coordinated by the Ministry for Health and Social Solidarity. Public health services are provided by the National Healthcare Service, or ESY (Greek: Εθνικό Σύστημα Υγείας, ΕΣΥ). In 2010 there were 35,000 hospital beds and 131 hospitals in the country.The Greek healthcare system has received high rankings by the World Health Organization, ranked 14th in the overall assessment and 11th in quality of service in a 2000 report by the WHO.Guernsey / Jersey[edit]The medical care system in the Channel Islands is very similar to that of the UK in that many of the doctors and nurses have been trained from the UK health perspective. There is universal health care for residents of the islands.[80]Iceland[edit]Iceland has a universal public health system paid largely from taxation with local municipalities delivering health care services in the same way as other Scandinavian countries. Iceland's entire population has equal access to health care services.Ireland[edit]The public health care system of the Republic of Ireland is governed by the Health Act 2004,[81]which established a new body to be responsible for providing health and personal social services to everyone living in Ireland – the Health Service Executive. The new national health service came into being officially on January 1, 2005; however the new structures are currently in the process of being established as the reform program continues. In addition to the public-sector, there is also a large private health care market.Isle of Man[edit]The Isle of Man provides universal public health coverage to its residents.[82]Italy[edit]Italy has a public health care service for all the residents called "Servizio Sanitario Nazionale" or SSN (National Health Service) which is similar to the UK National Health Service. It is publicly run and funded mostly from taxation: some services requires small co-pays, while other services (like the emergency medicine and the general doctor) are completely free of charge. Like the UK, there is a small parallel private health care system, especially in the field of Dental Medicine.Luxembourg[edit]Luxembourg provides universal health care coverage to all residents (Luxembourgers and foreigners) by the National Health Insurance (CNS - Caisse nationale de santé (French) or National Gesondheetskeess (Luxembourgish)) which is funded by mandatory contributions of employers and the workforce and by government subsidies for insuring jobseekers, the poor and for financing medical infrastructure. It exists as well a mandatory public long-term care insurance.[83][84]Netherlands[edit]The Netherlands has a dual-level system. All primary and curative care (i.e. the family doctor service and hospitals and clinics) is financed from private compulsory insurance. Long term care for the elderly, the dying, the long term mentally ill etc. is covered by social insurance funded from taxation. According to the WHO, the health care system in the Netherlands was 62% government funded and 38% privately funded as of 2004.[45]Insurance companies must offer a core universal insurance package for the universal primary, curative care which includes the cost of all prescription medicines. They must do this at a fixed price for all. The same premium is paid whether young or old, healthy or sick. It is illegal in The Netherlands for insurers to refuse an application for health insurance, to impose special conditions (e.g. exclusions, deductibles, co-pays etc., or refuse to fund treatments which a doctor has determined to be medically necessary). The system is 50% financed from payroll taxes paid by employers to a fund controlled by the Health regulator. The government contributes an additional 5% to the regulator's fund. The remaining 45% is collected as premiums paid by the insured directly to the insurance company. Some employers negotiate bulk deals with health insurers and some even pay the employees' premiums as an employment benefit). All insurance companies receive additional funding from the regulator's fund. The regulator has sight of the claims made by policyholders and therefore can redistribute the funds its holds on the basis of relative claims made by policy holders. Thus insurers with high payouts will receive more from the regulator than those with low payouts. Thus insurance companies have no incentive to deter high cost individuals from taking insurance and are compensated if they have to pay out more than might be expected. Insurance companies compete with each other on price for the 45% direct premium part of the funding and try to negotiate deals with hospitals to keep costs low and quality high. The competition regulator is charged with checking for abuse of dominant market positions and the creation of cartels that act against the consumer interests. An insurance regulator ensures that all basic policies have identical coverage rules so that no person is medically disadvantaged by his or her choice of insurer.Hospitals in the Netherlands are also regulated and inspected but are mostly privately run and not for profit, as are many of the insurance companies. Patients can choose where they want to be treated and have access to information on the internet about the performance and waiting times at each hospital. Patients dissatisfied with their insurer and choice of hospital can cancel at any time but must make a new agreement with another insurer.Insurance companies can offer additional services at extra cost over and above the universal system laid down by the regulator, e.g. for dental care. The standard monthly premium for health care paid by individual adults is about €100 per month. Persons on low incomes can get assistance from the government if they cannot afford these payments. Children under 18 are insured by the system at no additional cost to them or their families because the insurance company receives the cost of this from the regulator's fund. There is a fixed yearly threshold of €375 for each adult person, excluding first visits for diagnosis to general physicians.Norway[edit]Norway has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. Norway's entire population has equal access to health care services. The Norwegian health care system is government-funded and heavily decentralized. The health care system in Norway is financed primarily through taxes levied by county councils and municipalities. Dental care is included for children until 18 years old, and is covered for adults for some ailments.[85]Norway regularly comes top or close to the top of worldwide healthcare rankings.Portugal[edit]Portugal's National Healthcare Service, known nationally as Serviço Nacional de Saúde (SNS), is a universal and free healthcare service, provided nationwide since 1979, and is available to both Portuguese and foreigner residents. In 2014, Portugal SNS ranked 13th best healthcare service in Europe.[86]The National Medical Emergency Institute (INEM) is the main emergency medical serviced and can be activated by calling 112.Romania[edit]According to Article 34 of the Constitution of Romania, the state is obliged "to guarantee the protection of healthcare". Romania has a fully universal health care system, which covers up medical check-ups, any surgical interventions, and any post-operator medical care, as well as free or subsidized medicine for a range of diseases. The state is also obliged to fund public hospitals and clinics. Dental care is not funded by the state, although there are public dental clinics in some hospitals, which treat patients free of charge. However, due to inadequate funding and corruption, it is estimated that a third of medical expenses are, in some cases, supported by the patient.[87][clarification needed]Furthermore, Romania spends, per capita, less than any other EU state on medical care.Russia and Soviet Union[edit]In the Soviet Union, the preferred term was "socialist medicine"; the Russian language has no term to distinguish between "socialist" and "socialized" (other than "public", Rus: obshchestvenniy/общественный, sometimes "collectivized" or "nationalized", Rus: obobshchestvlenniy/обобществленный).[88][89]Russia in Soviet times (between 1917 and the early 1990s) had a totally socialist model of health care with a centralised, integrated, hierarchically organised with the government providing free health care to all citizens. Initially successful at combating infectious diseases, the effectiveness of the socialized model declined with underinvestment. Despite a doubling in the number of hospital beds and doctors per capita between 1950 and 1980, the quality of care began to decline by the early 1980s and medical care and health outcomes were below western standards.The new mixed economy Russia has switched to a mixed model of health care with private financing and provision running alongside state financing and provision. The OECD reported that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse.[90]The population's health has deteriorated on virtually every measure. The resulting system is overly complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from regional OMS funds to healthcare providers.Article 41 of the Constitution of the Russian Federation confirms a citizen's right to state healthcare and medical assistance free of charge.[91]This is achieved through state compulsory medical insurance (OMS) which is free to Russian citizens, funded by obligatory medical insurance payments made by companies and government subsidies.[92][93]Introduction in 1993 reform of new free market providers in addition to the state-run institutions intended to promote both efficiency and patient choice. A purchaser-provider split help facilitate the restructuring of care, as resources would migrate to where there was greatest demand, reduce the excess capacity in the hospital sector and stimulate the development of primary care. Russian Prime Minister Vladimir Putin announced a new large-scale health care reform in 2011 and pledged to allocate more than 300 billion rubles ($10 billion) in the next few years to improve health care in the country.[94]He also said that obligatory medical insurance tax paid by companies will increase from current 3.1% to 5.1% starting from 2011.[94]Serbia[edit]The Constitution of the Republic of Serbia states that it is a right of every citizen to seek medical assistance free of charge.[95]This is achieved by mutual contribution to the Compulsory Social Healthcare Fund of RZZO (Republički Zavod za Zdravstveno Osiguranje or National Health Insurance Institution). The amount of contribution depends on the amount of money the person is making. During the 1990s, Serbia's healthcare system has been of a poor quality due to severe underfunding. In the recent years, however, that has changed and the Serbian government has invested heavily in new medical infrastructure, completely remodeling existing hospitals and building two new hospitals in Novi Sad and Kragujevac.Sweden[edit]Sweden has a universal public health system paid largely from taxation in the same way as other Scandinavian countries. Sweden's entire population has equal access to health care services. The Swedish public health system is funded through taxes levied by the county councils, but partly run by private companies. Government-paid dental care for children under 21 years old is included in the system, and dental care for adults is somewhat subsidised by it.Sweden also has a smaller private health care sector, mainly in larger cities or as centers for preventive health care financed by employers.Sweden regularly comes in top in worldwide healthcare rankings.[96]Switzerland[edit]Healthcare in Switzerland is universal and is regulated by the Federal Health Insurance Act of 1994. Basic health insurance is mandatory for all persons residing in Switzerland (within three months of taking up residence or being born in the country). Insurers are required to offer insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.[97]United Kingdom[edit]Each of the Countries of the United Kingdom has a National Health Service that provides public healthcare to all UK permanent residents that was originally designed to be free at the point of need and paid for from general taxation; but changes included introducing charging for prescription medicines and dentistry (those below 16 and those on certain benefits may still get free treatment). However, since Health is now a devolved matter, considerable differences are developing between the systems in each of the countries as for example Scotland abolished prescription charges.[98]Private healthcare companies are free to operate alongside the public one.England[edit]Norfolk and Norwich University Hospital, a National Health Service hospital.The National Health Service (NHS), created by the National Health Service Act 1946, has provided the majority of healthcare in England since its launch on 5 July 1948.The NHS Constitution for England documents, at high level, the objectives of the NHS, the legal rights and responsibilities of the various parties (patients, staff, NHS trust boards), and the guiding principles which govern the service.[99]The NHS constitution makes it clear that it provides a comprehensive service, available to all irrespective of age, gender, disability, race, sexual orientation, religion, or belief; that access to NHS services is based on clinical need and not an individual's ability to pay; and that care is never refused on unreasonable grounds. Patient choice in terms of doctor, care, treatments, and place of treatment is an important aspect of the NHS's ambition, and in some cases patients can elect for treatment in other European countries at the NHS's expense. Waiting times are low, with most people able to see their primary care doctor on the same day or the following day.[100]Only 36.1% of hospital admissions are from a waiting list, with the remainder being either emergencies admitted immediately or else pre-booked admissions or the like (e.g., child birth).[101]One of the main goals of care management is to ensure that patients do not experience a delay of more than 18 weeks from initial hospital referral to final treatment, inclusive of time for all associated investigative tests and consultations.102]At present, two-thirds of patients are treated in under 12 weeks.[103]Although centrally funded, the NHS is not managed by a large central bureaucracy. Responsibility is highly devolved to geographical areas through Strategic Health Authorities and even more locally through NHS primary care trusts, NHS hospital trusts and increasingly to NHS foundation trusts which are providing even more decentralized services within the NHS framework, with more decision making taken by local people, patients, and staff. The central government office, the Department of Health, is not involved in day-to-day decision making in either the Strategic Health Authorities or the individual local trusts (primarily health, hospital, or ambulance) or the national specialist trusts such as NHS Blood and Transplant, but it does lay down general guidelines for them to follow. Local trusts are accountable to their local populations, whilst government ministers are accountable to Parliament for the service overall.The NHS provides, among other things, primary care, in-patient care, long-term healthcare, psychiatric care and treatments, ophthalmology, and dentistry. All treatment is free with the exception of certain charges for prescriptions, dentistry and ophthalmology (which themselves are free to children, certain students in full-time education, the elderly, the unemployed and those on low incomes). Around 89 pc of NHS prescriptions are obtained free of charge, mostly for children, pensioners, and pregnant women. Others pay a flat rate of £8.20,[104]and others may cap their annual charges by purchasing an NHS Prescription Prepayment Certificate. Private health care has continued parallel to the NHS, paid for largely by private insurance. Private insurance accounts for only 4 percent of health expenditure and covers little more than a tenth of the population.[105]Private insurers in the UK only cover acute care from specialists. They do not cover generalist consultations, pre-existing conditions, medical emergencies, organ transplants, chronic conditions such as diabetes, or conditions such as pregnancy or HIV.[106]Most NHS general practitioners are private doctors who contract to provide NHS services, but most hospitals are publicly owned and run through NHS Trusts. A few NHS medical services (such as "surgicentres") are sub-contracted to private providers[107]as are some non-medical services (such as catering). Some capital projects such as new hospitals have been funded through the Private Finance Initiative, enabling investment without (in the short term) increasing the public sector borrowing requirement, because long-term contractually obligated PFI spending commitments are not counted as government liabilities.Northern Ireland[edit]Health and Social Care in Northern Ireland is the designation of the national public health service in Northern Ireland.Scotland[edit]The Royal Aberdeen Children's Hospitalis a specialist children's hospital within NHS Scotland.NHS Scotland, created by the National Health Service (Scotland) Act 1947, was also launched on 5 July 1948, although it has always been a separate organization. Since devolution, NHS Scotland has followed the policies and priorities of the Scottish Government, including the phasing out of all prescription charges by 2011.[citation needed]Wales[edit]NHS Wales was originally formed as part of the same NHS structure created by the National Health Service Act 1946 but powers over the NHS in Wales came under the Secretary of State for Wales in 1969,[108]in turn being transferred under devolution to what is now the Welsh Government.North America[edit]The Bahamas,Barbados, Canada, Costa Rica, Cuba, Mexico, Panama, and Trinidad and Tobago all provide some level of universal health coverage.The Bahamas[edit]The Bahamas approved the National Health Insurance Act in August 2016. The legislation allows for the establishment of a universal health coverage system that will begin with universal coverage of primary health care services and later expand to include a wide set of benefits including all specialized care. The system will all for universal coverage of a basic benefit package and for voluntary insurance to be purchased as a top up policy to cover services or amenities that are not included in the government plan.[109]Canada[edit]In 1984, the Canada Health Act was passed, which prohibited extra billing by doctors on patients while at the same time billing the public insurance system. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."[110]The system is for the most part publicly funded, yet most of the services are provided by private enterprises or private corporations, although most hospitals are public. Most doctors do not receive an annual salary, but receive a fee per visit or service.[111]About 29% of Canadians' health care is paid for by the private sector or individuals.[112]This mostly goes towards services not covered or only partially covered by Medicare such as prescription drugs, dentistry and vision care.[113]Many Canadians have private health insurance, often through their employers, that cover these expenses.[114]The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.[115][116]The legality of the ban was considered in a decision of the Supreme Court of Canada which ruled in Chaoulli v. Quebec that "the prohibition on obtaining private health insurance, while it might be constitutional in circumstances where health care services are reasonable as to both quality and timeliness, is not constitutional where the public system fails to deliver reasonable services." The appellant contended that waiting times in Quebec violated a right to life and security in the Quebec Charter of Human Rights and Freedoms. The Court agreed, but acknowledged the importance and validity of the Canada Health Act, and at least four of the seven judges explicitly recognized the right of governments to enact laws and policies which favour the public over the private system and preserve the integrity of the public system.Costa Rica[edit]Universal healthcare and pensions are run by the Caja Costarricense de Seguro Social (CCSS). In 1941, Costa Rica established Caja Costarricense de Seguro Social (CCSS), a social security insurance system for wage-earning workers. In 1961, coverage was expanded to include workers’ dependents and from 1961 to 1975, a series of expansions extended coverage for primary care and outpatient and inpatient specialized services to people in rural areas, the low-income population, and certain vulnerable populations. Further expansions during the late 1970s extended insurance coverage to farmers, peasants, and independent contract workers. Additionally, CCSS mandates free health service provision to mothers, children, indigenous people, the elderly, and people living with disabilities, regardless of insurance coverage. By 2000, 82 percent of the population was eligible for CCSS, which has continued to expand in the ensuing period. By covering all population groups through the same system, Costa Rica has avoided social insurance stratification and inequity common in many other countries in the region.[117]CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions [6]. Taxes on luxury goods, alcohol, soda, and imported products also help to cover poor households who do otherwise pay into the system. All CCSS funds are merged into a single pool, which is managed by the central financial administration of CCSS. In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role. Responsibility for the provision of most care was transferred to the CCSS, although the Ministry retained responsibility for disease control, food and drug regulation, environmental sanitation, child nutrition, and primary care for the poor. Through the CCSS, health care is now essentially free to nearly all Costa Ricans. Private health care is also widely available and INS offers private health insurance plans to supplement CCSS insurance.[118]Cuba[edit]The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. The present Minister for Public Health is Roberto Morales Ojeda. However, although the coverage is wide, the system is underfunded and recently also understaffed. The government organized medical missions in other countries has taken a very significant amount of doctors and other personal. In 2005 there were 25000 Cuban doctors only in Venezuela.Mexico[edit]Public health care delivery is accomplished via an elaborate provisioning and delivery system instituted by the Mexican Federal Government. Public health care is provided to all Mexican citizens as guaranteed via Article 4 of the Constitution. Public care is either fully or partially subsidized by the federal government, depending on the person's (Spanish: derechohabiente's) employment status. All Mexican citizens are eligible for subsidized health care regardless of their work status via a system of health care facilities operating under the federal Secretariat of Health (formerly the Secretaria de Salubridad y Asistencia, or SSA) agency. Employed citizens and their dependents, however, are further eligible to use the health care program administered and operated by the Instituto Mexicano del Seguro Social (IMSS) (English: Mexican Social Security Institute). The IMSS health care program is a tripartite system funded equally by the employee, its private employer, and the federal government. The IMSS does not provide service to employees of the public sector. Employees in the public sector are serviced by the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) (English: Institute for Social Security and Services for State Workers), which attends to the health and social care needs of government employees. This includes local, state, and federal government employees. The government of the states in Mexico also provide health services independently of those services provided by the federal government programs. In most states, the state government has established free or subsidized healthcare to all their citizens.On December 1, 2006, the Mexican government created the Health Insurance for a New Generation also known as "life insurance for babies".[119][120][121]On May 16, 2009, Mexico to Achieve Universal Health Coverage by 2011.[122]On May 28, 2009, Mexico announced Universal Care Coverage for Pregnant Women.[123]On August 2012 Mexico installed a universal healthcare system.[124]Trinidad and Tobago[edit]Main article: Healthcare in Trinidad and TobagoA universal health care system is used in Trinidad and Tobago and is the primary form of health-care available in the country. It is used by the majority of the population seeking medical assistance, as it is free for all citizens.United States[edit]Main article: Patient Protection and Affordable Care ActSee also: Health care reform in the United States and Health care in the United StatesThe United States does not have a universal health care system. However, the Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act of 2010, seeks to have expanded insurance coverage to legal residents by 2014. It provides for federally mandated health insurance to be implemented in the United States during the 2010–2019 decade with the Federal government subsidizing legal resident households with income up to 400% of the Federal poverty level.[125]This threshold varies according to State and household size, but for an average family of four, subsidies would be available for families whose income was about $88,000 or lower.[126]In June 2010 adults with pre-existing conditions became eligible to join a temporary high-risk pool.[127]In 2014, applicants of the same age began to be able to obtain health insurance at the same published rate regardless of health status — the first time in U.S. history that insurers no longer had the right to load the premium or deny coverage prior to contract, or cancel a policy after contractdue to an adverse health condition, or test result indicating that one may be imminent. The law prohibits insurers from capping their liability for a person's health care needs, a move which is expected to rectify medically induced bankruptcy. As of April 13, 2015, the U.S. uninsured rate fell to 11.9% from the 17.1% recorded at the end of the fourth quarter of 2013. This is the lowest quarterly average recorded since Gallup and Healthwaysbegan tracking the percentage of uninsured Americans in 2008. Gallup attributed this sharp decline to the Affordable Care Act's requirements for most Americans to have healthcare in the beginning of the first quarter of 2014.[128]The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings,[129]partly from the elimination of insurance company overhead costs.[130]In 2009, a universal health care proposal was pending in Congress, the United States National Health Care Act (H.R. 676, formerly the "Medicare for All Act").The Congressional Budget Office (CBO) estimated that the bill would reduce the number of nonelderly people who are uninsured by about 32 million, leaving about 23 million nonelderly residents uninsured (about one-third of whom would be illegal immigrants). Under the legislation, the share of legal nonelderly residents with insurance coverage would rise from about 83 percent in 2010 to about 94 percent by 2019.[131]In May 2011, the state of Vermont became the first state to pass legislation establishing a single-payer health care system. The legislation, known as Act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of Vermont. The proposal was shelved not long after the main provisions of the law took effect in 2014.[132]A revised estimate in July 2012 by the CBO stated 30 million people would gain access to health insurance under the law.[133]Discussion in the United States commonly uses the term socialized medicine to impart a pejorative meaning to the idea of universal health care.South America[edit]Argentina, Brazil, Chile, Colombia, Peru, Uruguay, and Venezuela all have public universal health care provided.Argentina[edit]Health care is provided through a combination of employer and labor union-sponsored plans (Obras Sociales), government insurance plans, public hospitals and clinics and through private health insurance plans. It costs almost 10% of GDP and is available to anyone regardless of ideology, beliefs, race or nationality.Brazil[edit]The universal health care system was adopted in Brazil in 1988 after the end of the military regime's rule. However, universalized/socialized health care was available many years before, in some cities, once the 27th amendment to the 1969 Constitution imposed the duty of applying 6% of their income in healthcare on the municipalities.[134]Chile[edit]Health care in Chile is provided by the government (via Fonasa) and by private insurers (via Isapre). All workers and pensioners are mandated to pay 7% of their income for health care insurance (the poorest pensioners are exempt from this payment). Workers who choose not to join an Isapre, are automatically covered by Fonasa. Fonasa also covers unemployed people receiving unemployment benefits, uninsured pregnant women, insured worker's dependant family, people with mental or physical disabilities and people who are considered poor or indigent.Fonasa costs vary depending on income, disability or age. Attention at public health facilities via Fonasa is free for low-income earners, people with mental or physical disabilities and people over the age of 60. Others pay 10% or 20% of the costs, depending on income and number of dependants. Fonasa beneficiaries may also seek attention in the private sector, for a designated fee.Additionally, there are a number of high-mortality illnesses (currently 69) that have special attention guarantees for both Isapre and Fonasa affiliates, in relation to access to treatment, waiting times, maximum costs and quality of service.Colombia[edit]In 1993 a reform transformed the health care system in Colombia, trying to provide a better, sustainable, health care system and to reach every Colombian citizen.Peru[edit]On April 10, 2009, the Government of Peru published the Law on Health Insurance to enable all Peruvians to access quality health services, and contribute to regulate the financing and supervision of these services. The law enables all population to access diverse health services to prevent illnesses, and promote and rehabilitate people, under a Health Basic Plan (PEAS).[135][136]On April 2, 2010, President Alan Garcia Perez on Friday signed a supreme ordinance approving the regulations for the framework law on the Universal Health Insurance, which seeks to provide access to quality health care for all Peruvian citizens.Peru's Universal Health Insurance law aims to increase access to timely and quality health care services, emphasizes maternal and child health promotion, and provides the poor with protection from financial ruin due to illness.[137]The regulation states that membership of the Universal Health Insurance (AUS for its Spanish acronym) is compulsory for the entire population living in the country. To that end, the Ministry of Health will approve, by supreme ordinance, the mechanisms leading to compulsory membership, as well as escalation and implementation.[138]Oceania[edit]Australia and New Zealand have universal health care.Australia[edit]In Australia, Medibank — as it was then known — was introduced, by the Whitlam Labor government on July 1, 1975, through the Health Insurance Act 1973. The Australian Senate rejected the changes multiple times and they were passed only after a joint sitting after the 1974 double dissolution election. However, Medibank was supported by the subsequent Fraser Coalition (Australia) government and became a key feature of Australia's public policy landscape. The exact structure of Medibank/Medicare, in terms of the size of the rebate to doctors and hospitals and the way it has administered, has varied over the years. The original Medibank program proposed a 1.35% levy (with low income exemptions) but these bills were rejected by the Senate, and so Medibank was funded from general taxation. In 1976, the Fraser Government introduced a 2.5% levy and split Medibank in two: a universal scheme called Medibank Public and a government-owned private health insurance company, Medibank Private.During the 1980s, Medibank Public was renamed Medicare by the Hawke Labor government, which also changed the funding model, to an income tax surcharge, known as the Medicare Levy, which was set at 1.5%, with exemptions for low income earners.[139]The Howard Coalition government introduced an additional levy of 1.0%, known as the Medicare Levy Surcharge, for those on high annual incomes ($70,000) and do not have adequate levels of private hospital coverage.[140]This was part of an effort by the Coalition to encourage take-up of private health insurance. According to WHO, government funding covered 67.5% of Australia's health care expenditures in 2004; private sources covered the remaining 32.5% of expenditures.[45]New Zealand[edit]As with Australia, New Zealand's healthcare system is funded through general taxation. According to the WHO, government sources covered 77.4% of New Zealand's health care costs in 2004; private expenditures covered the remaining 22.6%.[45]

There is not much of a health plan that can become a replacement for the Patient Protection and Affordable Care Act of 2010, AKA Obamacare. It is likely to leave with no health care plan, just a patchwork of some Executive Orders that may still be applicable without the supporting PPACA in place, and lot of directives that have little force of law.The PPACA has provision for adults up to 26 years to be included on a parent’s healthcare plan, there is protection from being refused claims based on pre-existing conditions, there is a lifetime and annual maximum on out-of-pocket expenses, there are some states that have availed themselves to expand access to Medicare, there are tax rebate subsidies to support low-paid workers access to commercial and comprehensive health insurance plans if an employer does not offer anything, and some standards for Health Insurers and Providers. Nothing negative in the package, except that it is complex. There are 906 pages of detailed provisions across a range of Health Care issues. https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdfTrump’s healthcare is a an ‘ask’ for Pharmaceutical Companies to lower drug prices, make available cheap and cut-down Insurance Plans, provide some guarantees for Medicaid recipients with a lowest -price drug option, and removed the individual mandate tax penalty, weakening the participation in health care insurance. What is called a ‘Plan’ is just a list of initiatives that do not all have the weight and validity as a provision in a law, and will have no obligation to be followed - in this 8-page summary: https://www.govinfo.gov/content/pkg/FR-2020-10-01/pdf/2020-21914.pdfAs a plan, it is bankrupt, like its author. It merely summarizes positions, and does not wrap up an approach to Healthcare for all Americans, except for the assumption that if you are poor, you can die, and if you are rich, and might need to have coverage, their are a range of options now for you. If you are old, there is some Federal Support from what you have already paid for in Medicaid contributions, but do not hold out that it would last if you are not already on it now. Better that you read and understand that the emperor has no clothes, hence he stormed out of the 60 minutes meeting with Leslie Stahl as he does not understand what a Political. Government, or Legislative plan should entail.An America-First Healthcare PlanSection 1. Purpose. Since January 20, 2017, my Administration has beencommitted to the goal of bringing great healthcare to the American peopleand putting patients first. To that end, my Administration has taken monumental steps to improve the efficiency and quality of healthcare in theUnited States.(a) My Administration has been committed to restoring choice and controlto the American patient.On December 22, 2017, I signed into law the repeal of the burdensomeindividual-mandate penalty, liberating millions of low-income Americansfrom a tax that penalized them for not purchasing health-insurance coveragethey did not want or could not afford. Through Executive Order 13813of October 12, 2017 (Promoting Healthcare Choice and Competition Acrossthe United States), my Administration has expanded coverage options formillions of Americans in several ways. My Administration increased theavailability of renewable short-term, limited-duration healthcare plans, providing options that are up to 60 percent cheaper than the least expensivealternatives under the Patient Protection and Affordable Care Act (ACA)and are projected to cover 500,000 individuals who would otherwise beuninsured. My Administration expanded health reimbursement arrangements,which have been projected by the Department of the Treasury to reach800,000 businesses and over 11 million employees and to expand coverageto more than 800,000 individuals who would otherwise be uninsured. MyAdministration also issued a rule to increase the availability of associationhealth plans for small businesses, which, upon implementation of the rule,are projected to cover up to 400,000 previously uninsured individuals foron average 30 percent less cost.As set forth in the Economic Report of the President (February 2020), myAdministration’s expansion of health savings accounts will further helpmillions of Americans pay for health expenditures by allowing them tosave more of their own money free from Federal taxation, and will especiallyhelp Americans with chronic conditions who now have more flexibilityto enroll in plans that fit their complicated care needs and can be pairedwith a tax-advantaged account.At the beginning of the current COVID–19 pandemic, my Administrationacted to dramatically increase the accessibility and availability of telehealthservices for Medicare beneficiaries, enabling millions of individuals to usethese services. Pursuant to Executive Order 13941 of August 3, 2020 (Improving Rural Health and Telehealth Access), the Secretary of Health and HumanServices will make permanent many of the new policies that improve theaccessibility and availability of telehealth services. In addition, pursuantto that order, the Secretary of Health and Human Services and the Secretaryof Agriculture will develop and implement a strategy to improve the physicaland communications healthcare infrastructure available to rural Americans.Through our State Relief and Empowerment Waivers, my Administrationhas given States additional health-insurance flexibility, which has expandedhealth-insurance coverage options for consumers and lowered costs for patients. These waivers allow States to move away from the ACA’s rigidVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00003 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62180 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documentsstructure and are estimated to have lowered premiums by approximately11 percent in Wisconsin, 20 percent in Minnesota, and 43 percent in Maryland. Due to actions my Administration took, like the State Relief andEmpowerment Waivers, after years of dwindling choices and escalatingprices, plan options for consumers increased and for 2019, for the firsttime ever, benchmark premiums actually decreased on Get 2020 health coverage. Health Insurance Marketplace. For2020, the average benchmark premium dropped by nearly 4 percent.After the prior Administration spent tens of billions of dollars creatingelectronic health records systems unable to accurately or effectively recordand communicate patient data, my Administration has paved the way fora new wave of innovation to allow patients to safely send their own medicalrecords to care providers of their choosing. My Patients over Paperworkinitiative has cut red tape for doctors and nurses so they can spend moretime with their patients, which the Centers for Medicare and MedicaidServices (CMS) within the Department of Health and Human Services (HHS)has estimated to save over 40 million hours of wasted time for providersand suppliers between 2017 and 2021.(b) My Administration has been ceaseless in its efforts to lower coststo make healthcare more affordable for American patients.Under my tenure, prescription drugs saw their largest annual price decreasein nearly half a century. For three consecutive years, we have approveda record number of generic drugs. The Council of Economic Advisers hasestimated that these approvals saved patients $26 billion in the first 18months of my Administration alone. As part of the Further ConsolidatedAppropriations Act, 2020, I signed into law the Creating and RestoringEqual Access to Equivalent Samples Act, which will pave the way foreven more generic drugs and is projected to save taxpayers $3.3 billionfrom 2019 to 2029.CMS has acted to offer Medicare beneficiaries prescription drug plans withthe option of insulin capped at $35 in out-of-pocket expenses for a 30-day supply. We are also reducing Government payments to overcharginghospitals participating in the 340B Drug Pricing Program by instead payingrates that more accurately reflect the hospitals’ acquisition costs, whichCMS estimated would save Medicare beneficiaries $320 million on copayments for drugs alone.As a result of Executive Order 13937 of July 24, 2020 (Access to AffordableLife-Saving Medications), low-income Americans who receive care from afederally qualified health center will have access to insulin and injectableepinephrine at prices lower than ever before. Under Executive Order 13938of July 24, 2020 (Increasing Drug Importation to Lower Prices for AmericanPatients), my Administration will be the first to complete a rulemakingto authorize the safe importation of certain lower-cost prescription drugsfrom Canada. Pursuant to Executive Order 13939 of July 24, 2020 (LoweringPrices for Patients by Eliminating Kickbacks to Middlemen), my Administration is taking action to eliminate wasteful payments to middlemen by passingdrug discounts through to patients at the pharmacy counter without increasing premiums for beneficiaries or cost to Federal taxpayers. And my Administration is taking action to ensure that Medicare patients receive the lowestprice that drug companies offer comparable foreign nations through ExecutiveOrder 13948 of September 13, 2020 (Lowering Drug Prices by Putting AmericaFirst).As part of the Further Consolidated Appropriations Act, 2020, I also signedinto law the repeal of the medical device tax, the annual fee on healthinsurance providers, and the ‘‘Cadillac’’ tax on certain employer-sponsoredhealth insurance, which threatened to dramatically increase the cost ofhealthcare for working families.My Administration is transforming the black-box hospital and insurancepricing systems to be transparent about price and quality. Regardless ofhealth-insurance coverage, two-thirds of adults in America still worry aboutthe threat of unexpected medical bills. This fear is the result of a systemVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00004 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORDFederal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents 62181under which individuals and employers are unable to see how insurancecompanies, pharmacy benefit managers, insurance brokers, and providersare or will be paid. One major culprit is the practice of ‘‘surprise billing,’’in which a patient receives unexpected bills at highly inflated prices fromproviders who are not part of the patient’s insurance network, even ifthe patient was treated at a hospital that was part of the patient’s network.Patients can receive these bills despite having no opportunity to selectaround an out-of-network provider in advance.On May 9, 2019, I announced four principles to guide congressional effortsto prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians. Unfortunately, theCongress has failed to act, and patients remain vulnerable to surprise billing.In the absence of congressional action, my Administration has already takenstrong and decisive action to make healthcare prices more transparent. OnJune 24, 2019, I signed Executive Order 13877 (Improving Price and QualityTransparency in American Healthcare to Put Patients First), directing certainagencies—for the first time ever—to make sure patients have access to meaningful price and quality information prior to the delivery of care. BeginningJanuary 1, 2021, hospitals will be required to publish their real price forevery service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that areable to be shopped for in advance.We have also taken some concrete steps to eliminate surprise out-of-networkbills. For example, on April 10, 2020, my Administration required providersto certify, as a condition of receiving supplemental COVID–19 funding,that they would not seek to collect out-of-pocket expenses from a patientfor treatment related to COVID–19 in an amount greater than what thepatient would have otherwise been required to pay for care by an innetwork provider. These initiatives have made important progress, althoughadditional efforts are necessary.Not all hospitals allow for surprise bills. But many do. Unfortunately, surprisebilling has become sufficiently pervasive that the fear of receiving a surprisebill may dissuade patients from seeking appropriate care. And researchsuggests a correlation between hospitals that frequently allow surprise billingand increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physicalharm and threatens the long-term financial sustainability of Medicare.Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they workwould correspondingly streamline the ability of patients to receive careand reduce time spent on billing disputes.On May 15, 2020, HHS released the Health Quality Roadmap to empowerpatients to make fully informed decisions about their healthcare by facilitating the availability of appropriate and meaningful price and quality information. These transformative actions will arm patients with the tools tobe active and effective shoppers for healthcare services, enabling them toidentify high-value providers and services, and ultimately place downwardpressure on prices.My Administration has cracked down on waste, fraud, and abuse that directvaluable taxpayer resources away from those who need them most. MyAdministration implemented a ‘‘site neutral’’ payment system between hospital outpatient departments and physicians’ offices, to ensure Medicarebeneficiaries are charged the same price for the same service regardlessof where it takes place, which CMS estimates will save them approximately$160 million in co-payments for 2020. We also changed the rules to enableGovernment watchdogs to proactively identify and stop perpetrators of fraudbefore money goes out the door.(c) My Administration has been dedicated to providing better care forall Americans.VerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00005 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62182 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential DocumentsThis includes a steadfast commitment to always protecting individuals withpre-existing conditions and ensuring they have access to the high-qualityhealthcare they deserve. No American should have to risk going withouthealth insurance based on a health history that he or she cannot change.In an attempt to justify the ACA, the previous Administration claimedthat, absent action by the Congress, up to 129 million (later updated to133 million) non-elderly people with what it described as pre-existing conditions were in danger of being denied health-insurance coverage. Accordingto the previous Administration, however, only 2.7 percent of such individualsactually gained access to health insurance through the ACA, given existinglaws and programs already in place to cover them. For example, the HealthInsurance Portability and Accountability Act of 1996 has long protectedindividuals with pre-existing conditions, including individuals covered bygroup health plans and individuals who had such coverage but lost it.The ACA produced multiple other failures. The average insurance premiumin the individual market more than doubled from 2013 to 2017, and thosewho have not received generous Federal subsidies have struggled to maintaincoverage. For those who have managed to maintain coverage, many haveexperienced a substantial rise in deductibles, limited choice of insurers,and limited provider networks that exclude their doctors and the facilitiesbest suited to care for them.Additionally, approximately 30 million Americans remain uninsured, notwithstanding the previous Administration’s promises that the ACA wouldaddress this intractable problem. On top of these disappointing results,Federal taxpayers and, unfortunately, future generations of American workers,have been left with an enormous bill. The ACA’s Medicaid expansion andsubsidies for the individual market are projected by the Congressional BudgetOffice to cost more than $1.8 trillion over the next decade.The ACA is neither the best nor the only way to ensure that Americanswho suffer from pre-existing conditions have access to health-insurancecoverage. I have agreed with the States challenging the ACA, who havewon in the Federal district court and court of appeals, that the ACA, asamended, exceeds the power of the Congress. The ACA was flawed fromits inception and should be struck down. However, access to health insurancedespite underlying health conditions should be maintained, even if theSupreme Court invalidates the unconstitutional, and largely harmful, ACA.My Administration has always been committed to ensuring that patientswith pre-existing conditions can obtain affordable healthcare, to loweringhealthcare costs, to improving quality of care, and to enabling individualsto choose the healthcare that meets their needs. For example, when theCOVID–19 pandemic hit, my Administration implemented a program toprovide any individual without health-insurance coverage access to necessaryCOVID–19-related testing and treatment.My commitment to improving care across our country expands vastly beyondthe rules governing health insurance. On July 10, 2019, I signed ExecutiveOrder 13879 (Advancing American Kidney Health) to improve care for thehundreds of thousands of Americans suffering from end-stage renal disease.Pursuant to that order, my Administration launched a program to encouragehome dialysis and promote transplants for patients, and expects to enrollapproximately 120,000 Medicare beneficiaries with end-stage renal diseasein the program. We also have removed financial barriers to living organdonation by adding additional financial support for living donors, suchas by reimbursing expenses for lost wages, child care, and elder care. HHS,together with the American Society of Nephrology, issued two phases ofawards through KidneyX’s Redesign Dialysis Price Competition to worktoward the creation of an artificial kidney.My Administration has taken unprecedented action to improve the qualityof and access to care for individuals with HIV, as part of our goal ofending the epidemic of HIV in the United States by 2030. HHS has awardedVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00006 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORDFederal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents 62183at least $226 million to expand access to HIV care, treatment, medication,and prevention services, focused on 48 counties, Washington, DC, and SanJuan, Puerto Rico, where more than 50 percent of new HIV diagnoses occurredin 2016 and 2017, as well as seven States with a substantial rural HIVrate. We secured a historic donation of a groundbreaking HIV preventivemedication that is available at no cost to eligible patients.My Administration has started a transformation in healthcare in rural America. This includes a new effort, pursuant to my directive in Executive Order13941, to support small hospitals and health clinics in rural communitiesin transitioning from volume-based Medicare and Medicaid reimbursement,which has failed rural communities that struggle with a lack of patientvolume, and toward value-based payment mechanisms that are tailored tomeet the needs of their communities. We updated Medicare payment policiesto address a problem in the program’s payment calculation that has historically disadvantaged rural hospitals, and released a Rural Action Plan toincorporate recommendations from experts and leaders across the FederalGovernment. We have also dedicated a special focus on improving careoffered through the Indian Health Service (IHS) within HHS, including bycreating the Office of Quality, implementing an increase in annual fundingfor IHS by $243 million from 2019 to 2020, and expanding nationwideIHS’s successful Alaska Community Health Aide Program.My Administration has additionally demonstrated an incredible dedicationto protecting and improving care for those most in need, including seniorcitizens, those with substance use disorders, and those to whom our Nationowes the greatest debt: our veterans.I have protected the viability of the Medicare program. For example, onFebruary 9, 2018, I signed into law the repeal of the Independent PaymentAdvisory Board, which would have been a group of unelected bureaucratscreated by the ACA, designed to be insulated from the will of America’selected leaders for the purpose of cutting the spending of this importantprogram. On October 3, 2019, I signed Executive Order 13890 (Protectingand Improving Medicare for Our Nation’s Seniors), to modernize the Medicareprogram and continue its viability. According to CMS estimates, seniorshave saved $2.65 billion in lower Medicare premiums under my Administration while benefiting from more choices. For example, the average monthlyMedicare Advantage premium has declined an estimated 28 percent since2017, and Medicare Advantage has included about 1,200 more plan optionssince 2018. New Medicare Advantage supplemental benefits have helpedseniors stay safe in their homes, improved respite care for caregivers, andprovided transportation, more in-home support services and assistance, andnon-opioid pain management alternatives like therapeutic massages. MedicarePart D premiums are at their lowest level in their history, with the averagebasic premium declining 13.5 percent since 2016.My Administration has directed unprecedented attention on the substanceuse disorder epidemic, with a focus on reducing overdose deaths fromprescription opioids and the deadly synthetic opioid fentanyl. On October24, 2018, I signed the Substance Use-Disorder Prevention that PromotesOpioid Recovery and Treatment for Patients and Communities Act, enablingthe expenditure of billions of dollars of funding for important programsto support prevention and recovery. My Administration has provided approximately $22.5 billion from 2017 to 2020 to address the opioid crisisand improve access to prevention, treatment, and recovery services. Wesaw a 34 percent decrease in total opioids dispensed monthly by pharmaciesbetween 2017 and 2019, an approximate increase of 64 percent in thenumber of Americans who receive medication-assisted treatment for opioiduse disorder since 2016, and a 484 percent increase in naloxone prescriptionssince 2017. Data show that drug overdose deaths fell nationwide for thefirst time in decades between 2017 and 2018, with many of the hardesthit States leading the way.VerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00007 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62184 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential DocumentsImproving care for our Nation’s veterans has been a priority since the beginning of my Administration. On June 6, 2018, I signed the VA MaintainingInternal Systems and Strengthening Integrated Outside Networks (MISSION)Act of 2018, which authorized billions of dollars to improve options forveterans to receive care outside of Department of Veterans Affairs (VA)healthcare providers. Since taking effect, the VA estimates that more than2.4 million veterans have benefited from more than 6.5 million referralsto the 725,000 private healthcare providers with which the VA is nowworking. On June 23, 2017, I signed the Department of Veterans AffairsAccountability and Whistleblower Protection Act of 2017 to hold our civilservants accountable for maintaining the best quality of care possible forour Nation’s veterans by giving the Secretary of Veterans Affairs more powerto discipline employees and shorten an appeals process that can last years.On March 5, 2019, I signed Executive Order 13861 (National Roadmapto Empower Veterans and End Suicide) to ensure that the Federal Governmentleads a collective effort to prevent suicide among our veterans.I have used scientific research to focus on areas most pressing for thehealth of Americans. On September 19, 2019, I signed Executive Order13887 (Modernizing Influenza Vaccines in the United States to PromoteNational Security and Public Health), recognizing the threat that pandemicinfluenza continues to represent and putting forward a plan to preparefor future influenza pandemics. To modernize influenza vaccines and promote national security and public health, HHS issued a 6-year, $226 millioncontract to retain and increase capacity to produce recombinant influenzavaccine domestically, and the National Institute of Allergy and InfectiousDiseases, part of the National Institutes of Health within HHS, initiatedthe Collaborative Influenza Vaccine Innovation Centers program.Investments my Administration has made in scientific research will helptackle some of our most pressing medical challenges and pay dividendsfor generations to come. This includes working to increase funding forAlzheimer’s disease research by billions of dollars since 2017 and a planto invest more than $500 million over the next decade to improve pediatriccancer research. On December 18, 2018, I signed the Sickle Cell Diseaseand Other Heritable Blood Disorders Research, Surveillance, Prevention,and Treatment Act of 2018 to provide support for research into sicklecell disease, which disproportionately impacts African Americans and Hispanics, and to authorize programs relating to sickle cell disease surveillance,prevention, and treatment.On May 30, 2018, I signed the Trickett Wendler, Frank Mongiello, JordanMcLinn, and Matthew Bellina Right to Try Act of 2017, which gives terminally ill patients the right to access certain treatments without being blockedby onerous Federal regulations.In response to the COVID–19 pandemic, my Administration launched Operation Warp Speed, a groundbreaking effort of the Federal Government toengage with the private sector to quickly develop and deliver safe andeffective vaccines, therapeutics, and diagnostics for COVID–19. On August6, 2020, I signed Executive Order 13944 (Combating Public Health Emergencies and Strengthening National Security by Ensuring Essential Medicines,Medical Countermeasures, and Critical Inputs Are Made in the United States),to protect Americans through reduced dependence on foreign manufacturersfor essential medicines and other items and to strengthen the Nation’s PublicHealth Industrial Base.Taken together, these extraordinary reforms constitute an ongoing effort toimprove American healthcare by putting patients first and delivering continuous innovation. And this effort will continue to succeed because of myAdministration’s commitment to delivering great healthcare with morechoices, better care, and lower costs for all Americans.Sec. 2. Policy. It has been and will continue to be the policy of the UnitedStates to give Americans seeking healthcare more choice, lower costs, andVerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00008 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORDFederal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents 62185better care and to ensure that Americans with pre-existing conditions canobtain the insurance of their choice at affordable rates.Sec. 3. Giving Americans More Choice in Healthcare. The Secretary of theTreasury, the Secretary of Labor, and the Secretary of Health and HumanServices shall maintain and build upon existing actions to expand accessto and options for affordable healthcare.Sec. 4. Lowering Healthcare Costs for Americans. (a) The Secretary of Healthand Human Services, in coordination with the Commissioner of Food andDrugs, shall maintain and build upon existing actions to expand accessto affordable medicines, including accelerating the approvals of new genericand biosimilar drugs and facilitating the safe importation of affordable prescription drugs from abroad.(b) The Secretary of the Treasury, the Secretary of Labor, and the Secretaryof Health and Human Services shall maintain and build upon existing actionsto ensure consumers have access to meaningful price and quality informationprior to the delivery of care.(i) Recognizing that both chambers of the Congress have made substantialprogress towards a solution to end surprise billing, the Secretary of Healthand Human Services shall work with the Congress to reach a legislativesolution by December 31, 2020.(ii) In the event a legislative solution is not reached by December 31,2020, the Secretary of Health and Human Services shall take administrativeaction to prevent a patient from receiving a bill for out-of-pocket expensesthat the patient could not have reasonably foreseen.(iii) Within 180 days of the date of this order, the Secretary of Healthand Human Services shall update the Medicare.gov: the official U.S. government site for Medicare Hospital Comparewebsite to inform beneficiaries of hospital billing quality, including:(A) whether the hospital is in compliance with the Hospital Price Transparency Final Rule, as amended (84 Fed. Reg. 65524), effective January1, 2021;(B) whether, upon discharge, the hospital provides patients with a receiptthat includes a list of itemized services received during a hospital stay;and(C) how often the hospital pursues legal action against patients, includingto garnish wages, to place a lien on a patient’s home, or to withdrawmoney from a patient’s income tax refund.(c) The Secretary of Health and Human Services, in coordination withthe Administrator of CMS, shall maintain and build upon existing actionsto reduce waste, fraud, and abuse in the healthcare system.Sec. 5. Providing Better Care to Americans. (a) The Secretary of Healthand Human Services and the Secretary of Veterans Affairs shall maintainand build upon existing actions to improve quality in the delivery of carefor veterans.(b) The Secretary of Health and Human Services shall continue to promotemedical innovations to find novel and improved treatments for COVID–19, Alzheimer’s disease, sickle cell disease, pediatric cancer, and other conditions threatening the well-being of Americans.Sec. 6. General Provisions. (a) Nothing in this order shall be construedto impair or otherwise affect:(i) the authority granted by law to an executive department or agency,or the head thereof; or(ii) the functions of the Director of the Office of Management and Budgetrelating to budgetary, administrative, or legislative proposals.(b) This order shall be implemented consistent with applicable law andsubject to the availability of appropriations.VerDate Sep<11>2014 21:36 Sep 30, 2020 Jkt 253001 PO 00000 Frm 00009 Fmt 4705 Sfmt 4790 E:\FR\FM\01OCE0.SGM 01OCE0jbell on DSKJLSW7X2PROD with EXECORD62186 Federal Register / Vol. 85, No. 191 / Thursday, October 1, 2020 / Presidential Documents(c) This order is not intended to, and does not, create any right or benefit,substantive or procedural, enforceable at law or in equity by any partyagainst the United States, its departments, agencies, or entities, its officers,employees, or agents, or any other person.

“We dance round in a ring and suppose, but the secret sits in the middle and knows.”ROBERT FROST 1945“In Florida today, theaters are open, concerts are happening, and the iconic theme parks are accepting visitors (if on a somewhat restricted basis).”The strict lockdown in the UK also arrested the virus in Sweden - oops without a lockdown???Contrast Between New York And Florida — Manhattan ContrarianNEW LANCET RESEARCH: “Covid 19 is not a PANDEMIC.”“The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail.” LANCETNOT A PANDEMIC BUT A SYNDEMIC“Coronavirus is no 1918 ‘Spanish’ Influenza that struck down a global population in its prime: this virus is overwhelmingly targeting people who would already be vulnerable to disease. From the available data, then, there is cause to suggest that this is not a pandemic, but a syndemic.”Pandemic … or syndemic? Re‐framing COVID‐19 disease burden and ‘underlying health conditions’“Many seriously ill COVID-19 patients had multiple comorbidities (26); for instance, 96.2% of those who died in hospitals in Italy had comorbidities..If We Just Treat COVID-19 as a Pandemic, We’re ScrewedWe’re in a syndemic, when an illness and our broken society combine to bring terrible things. Here’s how we need to respond.Crawford Kilian 30 Sep 2020 | The Tyee | Home80% CANADA’S COVID 19 DEATHS WERE IN LONG TERM CARE HOMES“Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.” Richard HortonIf We Just Treat COVID-19 as a Pandemic, We’re Screwed | The TyeeCOMORBIDITY IS EVERYTHING WITH THIS VIRUS.“Many seriously ill COVID-19 patients had multiple comorbidities (26); for instance, 96.2% of those who died in hospitals in Italy had comorbidities..The prevalence of comorbidities is higher among COVID-19 patients compared to the general population who are not infected with coronavirus; for instance, 86% of the COVID-19 patients in India and 72% of the COVID-19 patients in China had comorbidities (28). ““NEW RESEARCH WITH FOCUS ON THE SYNDEMIC ISSUEThe global coronavirus disease (COVID-19) pandemic has greatly affected the lives of people living with non-communicable diseases (PLWNCDs). The health of PLWNCDs worsens when synergistic epidemics or “syndemics” occur due to the interaction between socioecological and biological factors, resulting in adverse outcomes. These interactions can affect the physical, emotional, and social well-being of PLWNCDs. In this paper, we discuss the effects of the COVID-19 syndemic on PLWNCDs, particularly how it has exposed them to NCD risk factors and disrupted essential public health services. We conclude by reflecting on strategies and policies that deal with the COVID-19 syndemic among PLWNCDs in low- and middle-income countries.ConclusionCOVID-19 and NCDs have a reciprocal effect on each other; NCDs increase vulnerability to COVID-19, and COVID-19 increases NCD-related risk factors. The COVID-19 pandemic may not be the last to threaten the global community. Therefore, there is a need to understand the drivers of the syndemic and design safety nets. The health system must address not just one or some medical problems but ensure holistic care for those that need it, particularly PLWNCDs. Care for PLWNCDs, who are at most risk of COVID-19, must be included in national response frameworks and plans so that the government can protect citizens' health and well-being during the current COVID-19 pandemic and for similar crises in the future, otherwise, the interaction of COVID-19 and NCDs will result in disastrous effects that could be difficult to handle given the preexisting stress on healthcare delivery systems and impede progress in achieving the Sustainable Development Goals.”A Syndemic Perspective on the Management of Non-communicable Diseases Amid the COVID-19 Pandemic in Low- and Middle-Income CountriesCDC: “only 6% of deaths are solely from COVID 19” THIS IS A SYNDEMIC. We must broaden are concern and address hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer,” to stop the spread. LANCETDr. Fauci weighs in on 6M US coronavirus cases, deaths and comorbidityThe top health official speaks to "GMA" about the CDC's adjusted numbers that listed 6% of deaths solely caused by COVID-19 and what it means for those with underlying conditions.September 1, 2020“On Sept. 1, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), debunked the claim on ABC’s Good Morning America ( here ).Asked to explain “why the president would retweet a theory that suggests only 9,000 people have died of COVID-19,” Fauci said, “The point that the CDC was trying to make was that a certain percentage of (Americans who have died of COVID-19) had nothing else but just COVID. That does not mean that someone who has hypertension or diabetes who dies of COVID didn’t die of COVID-19. They did.”“A small number of people have COVID ascribed as the sole cause of death. It may be they had no comorbidities or they were just not noted,” Myron Cohen, director of the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill, tells PolitiFact. “However, it is also clear that advanced age and several other underlying diseases lead to bad outcomes with COVID infections. The people dying were not going to die but for the acquisition of COVID.”Mark Halstead, a sports team physician at Washington University, described a hypothetical scenario in a Facebook post on August 30. Someone coming to the hospital with COVID-19 would certainly have the virus listed as a primary diagnosis, but if they then required a ventilator, respiratory failure would also be listed as a cause of death. If a person were to decline to such an extent that they went into cardiac arrest and died, that too would be listed on a death certificate. “The COVID infection started the process but that led to the heart and lungs failing, which killed that person,” Halstead says.No, the CDC Has Not “Quietly Updated” COVID-19 Death EstimatesBut that’s not what the CDC information says.In weekly updates provided on the CDC’s website, the agency includes information on additional conditions present in patients who died with COVID-19. These other illnesses or conditions found to be present in a patient are called comorbidities. The agency also includes a chart detailing the number of patients with each additional condition.For the week referenced in the claim, the CDC explained that the chart “shows the types of health conditions and contributing causes mentioned in conjunction with deaths involving coronavirus disease 2019 (COVID-19). For 6% of the deaths, COVID-19 was the only cause mentioned.”That means that 6% of those who died with COVID-19 through Aug. 15 didn’t have any other reported conditions.CDC Did Not 'Admit Only 6%' of Recorded Deaths from COVID-19AGE AND PRE-EXISTING CONDITIONS IS THE WHOLE SHOW FOR COVID 19FOLLOW THE NCD NON COMMUNICABLE DISEASESI submit If you revise your view of Covid as a syndemic rather than a pandemic you will better understand the variability in countries and people world wide. It is not just who followed the guidelines best but who has the most vulnerable underlying health issues that has the worst outcomes with hypertension and diabetes at the top.”From the beginning the impacts of Covid 19 have been uneven hitting some countries, the elderly and disadvantage far harder than others.China’s new research published in the JOURNAL OF ERS shows “hypertension and diabetes” are the major comorbidities for Covid 19 - See ABSTRACT below.“However, comorbidities do not seem to be the prerequisite for symptomatic and severe COVID-19 infection, except hypertension.Prevalence of Comorbidities in COVID-19 Patients: A Systematic Review and Meta-AnalysisSee ABSTRACT below.Most common comorbidities in COVID-19 deceased patients in Italy 2020Published by Statista Research Department, Aug 18, 2020An in depth study on patients admitted to hospital and later deceased with the coronavirus (COVID-19) infection revealed that the majority of cases showed one or more comorbidities. As the chart shows, hypertension was the most common pre-existing health condition, detected in 66 percent of patients who died after contracting the virus. Type 2-diabetes, chronic renal failure, and ischemic hearth disease were also among the most common comorbidities in COVID-19 patients who lost their lives.Italy’s First WaveThe most plausible explanation for this discrepancy is a short-term decrease in mortality after the first phase of the pandemic, which affected mainly older adults and those with underlying chronic conditions, 4, 5 a phenomenon known as the harvesting effect. In fact, the median age at death of patients who died and tested positive for SARS-CoV-2 infection was 82 years; 95% of them had at least one comorbidity, and 60% had at least three comorbidities before being infected. This phenomenon was less evident in Lombardy, where the number of cases, although remarkably reduced in the second half of May, 2020, continued to be non-negligible. More importantly, a large number of patients who had tested positive for SARS-CoV-2 might have died in May of other causes, although their deaths were attributed to COVID-19.”LANCETItaly's first wave of the COVID-19 pandemic has ended: no excess mortality in May, 2020WHY? THE ANSWER IS THAT COVID IS NOT A PANDEMIC. IT IS A SYNDEMIC.The full weight of public attention has been too narrow with too much concern about testing for Covid and too little concern about underlying disease that compromise our immune systems.Coronavirus World Map: Tracking The Spread Of The Outbreak | WAMUTotal casesDeathsPer capitaHOT SPOTS“The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, pursuit of a purely biomedical solution to COVID-19 will fail.Why context matters when there is comorbidity in play. The world has flunked the Covid crisis by ignoring the syndemic reality which means for example that almost all victims of the virus are also victims for example of diabetes, morbid obesity and hearth disease.”Offline: COVID-19 is not a pandemicAuthor links open overlay panelRichardHortonhttps://doi.org/10.1016/S0140-6736(20)32000-6Get rights and content“As the world approaches 1 million deaths from COVID-19, we must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus. We have viewed the cause of this crisis as an infectious disease. All of our interventions have focused on cutting lines of viral transmission, thereby controlling the spread of the pathogen. The “science” that has guided governments has been driven mostly by epidemic modellers and infectious disease specialists, who understandably frame the present health emergency in centuries-old terms of plague. But what we have learned so far tells us that the story of COVID-19 is not so simple. Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities.The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. A syndemic is not merely a comorbidity. Syndemics are characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment. As our recently published NCD Countdown 2030 showed, although premature mortality from NCDs is falling, the pace of change is too slow. The total number of people living with chronic diseases is growing. Addressing COVID-19 means addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer. Paying greater attention to NCDs is not an agenda only for richer nations. NCDs are a neglected cause of ill-health in poorer countries too. In their Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest billion people in the world today, NCDIs make up over a third of their burden of disease. The Commission described how the availability of affordable, cost-effective interventions over the next decade could avert almost 5 million deaths among the world's poorest people. And that is without considering the reduced risks of dying from COVID-19.The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged—namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail. Unless governments devise policies and programmes to reverse profound disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues wrote in 2017, “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.” I would add one further advantage. Our societies need hope. The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.Covid-19 is really a syndemic — and that shows us how to fight itCoronavirus does not act alone but with co-morbidities such as obesity and diabetes Please use the sharing tools found via the share button at the top or side of articles. Copying articles to share with others is a breach of Financial Times T&Cs and Copyright Policy. Email [email protected] to buy additional rights. Subscribers may share up to 10 or 20 articles per month using the gift article service. More information can be found at Take a tour - Hints and tips on getting more from your subscription - FT.com.This messy tangle of interacting epidemics is why we should consider Covid-19 a syndemic, according to Richard Horton, editor of the Lancet medical journal, who argues against a narrow “plague” narrative in a recent editorial.“Focusing on the virus alone is a mistake,” he told me, of the single-minded pursuit of Covid-19 treatments and vaccines. The deadly impact of the pandemic “is not caused by the virus acting alone but interacting with chronic diseases like diabetes, obesity, heart disease and high blood pressure — all against a background of inequality and poverty. We can’t fully control the infection without addressing those factors.”Effects of pandemic will widen inequality, report findsDoesn’t expanding the coronavirus pandemic into a syndemic widen the problem and induce a greater sense of hopelessness? Mr Horton claims the opposite as “it gives you a whole range of measures to implement right now to protect people while we wait for a vaccine”. His basic prescription is to tackle those familiar epidemics: cut obesity, improve the treatment of diabetes, heart disease and cancer, among other illnesses. That means paying attention to keeping health systems afloat for other conditions.Obesity was a risk factor for both UK prime minister Boris Johnson and US president Donald Trump in their illnesses. The UK government unveiled a new obesity strategy in July, with promises to stop multi-buy offers on unhealthy foods and clamp down on junk-food advertising. But that feels like nibbling at the edges of a meatier problem that Mr Horton and, most notably, epidemiologist Michael Marmot have identified: the influence of poverty and inequality on health.”Volume 396, Issue 10255, 26 September–2 October 2020, Page 874https://www.sciencedirect.com/science/article/pii/S0140673620320006A non-communicable disease (NCD) is a disease that is not transmissible directly from one person to another. NCDs include Parkinson's disease, autoimmune diseases, strokes, most heart diseases, most cancers, diabetes, chronic kidney disease, osteoarthritis, osteoporosis, Alzheimer's disease, cataracts, and others.Includes Diseases: DiabetesNon-communicable disease - WikipediaHe then confirmed that the recorded 180,000 American deaths “are real deaths from COVID-19.”The double burden of nutrition: When malnutrition and obesity overlap18-Dec-2019 By Danielle MastersonThe Lancet recently published a warning report calling attention to the “new nutrition reality” facing low and middle-income countries that is driven by the modern food system.HTTPS://WWW.NUTRAINGREDIENTS-USA.COM/ARTICLE/2019/12/18/THE-DOUBLE-BURDEN-OF-NUTRITION-WHEN-MALNUTRITION-AND-OBESITY-OVERLAPWuhan Virus Archives - The FederalistBiden says it’s not political, but “this deadly virus has been the greatest political gift to the Democratic Party since the Great Depression,” Hemingway said.https://thefederalist.com/category/wuhanvirus/Study: Majority Of Americans Grossly Overestimated COVID HospitalizationA new study revealed a majority of voters on both sides of the political aisle believed exaggerated claims about COVID-19 and its effects.https://thefederalist.com/2021/03/22/study-majority-of-americans-grossly-overestimated-covid-19-hospitalization-rates/MARCH 22, 2021 By Jordan DavidsonA new study revealed a majority of voters on both sides of the political aisle believed exaggerated claims about COVID-19 and the effects it would have on people including children.While the survey of 35,000 from Gallup and Franklin Templeton showed that Democrats were more likely to overestimate the severity of COVID-19, such as the risk of death the virus posed to children and teens, and Republicans were more likely to underestimate the virus’s toll, a majority of voters on the left, right, and middle of the political aisle all overstated the effect coronavirus had on multiple factors including hospitalization rates.The current hospitalization rate for COVID-related illness in the United States hovers between 1 and 5 percent, but 41 percent of Democrats, 28 percent of Republicans, and 35 percent of independents or members of other political parties said there is a 50-plus percent chance that someone with the Wuhan virus will need to be treated at a hospital.This incorrect yet general consensus, the New York Times noted, was often reinforced with widespread policy decisions by partisan actors, such as Democratic politicians in blue states and cities keeping schools closed despite scientific evidence pointing to reopening while red states started to transition back to in-person models as early as August.“I think in many ways it’s based on the fact that these voters are misinformed about the risks to young people and they’re misinformed about the risks generally,” Gallup’s principal economist Jonathan Rothwell said.Corporate media was quick to pick up the panic narrative about COVID-19, condemning Republican governors for refusing to lock down, despite the scientific data suggesting that prolonged lockdowns would take a large metal and physical toll on people. Journalists also often misconstrued scientific data to fit a fearmongering narrative and employed the censorship efforts of eager Big Tech companies to obscure scientific studies and testimonies about the effects and potential treatment of the virus.Jordan Davidson is a staff writer at The Federalist. She graduated from Baylor University where she majored in political science and minored in journalism.Photo Pexels/PhotoPhoto U.S. Air Force photo/Senior Airman Nicholas Dutton3C epiphanyThe Japanese authorities understood covid-19 better than mostThat has helped keep Japan’s outbreak relatively smallAsiaDec 12th 2020 editionECONOMIST PHOTO AND STORYDec 12th 2020TOKYO“When the Diamond Princess, a cruise ship suffering from an outbreak of covid-19, arrived in Japan in February, it seemed like a stroke of bad luck. A small floating petri dish threatened to turn the Japanese archipelago into a big one. In retrospect, however, the early exposure taught the authorities lessons that have helped make Japan’s epidemic the mildest among the world’s big economies, despite a recent surge in infections. In total 2,487 people have died of the coronavirus in Japan, just over half the number in China and fewer people than on a single day in America several times over the past week. Japan has suffered just 18 deaths per million people, a higher rate than in China, but by far the lowest in the g 7, a club of big, industrialised democracies. (Germany comes in second, at 239.) Most strikingly, Japan has achieved this success without strict lockdowns or mass testing—the main weapons in the battle against covid-19 elsewhere.“From the beginning we did not aim at containment,” says Oshitani Hitoshi, a virologist who sits on an expert panel advising the government. That would require identifying all possible cases, which is not feasible in a country of Japan’s size when the majority of infections produce mild or no symptoms, argues Mr Oshitani: “Even if you test everyone once per week, you’ll still miss some.”The Japanese authorities understood covid-19 better than mostThis Overlooked Variable Is the Key to the PandemicIt’s not R.ZEYNEP TUFEKCISEPTEMBER 30, 2020“Perhaps one of the most interesting cases has been Japan, a country with middling luck that got hit early on and followed what appeared to be an unconventional model, not deploying mass testing and never fully shutting down. By the end of March, influential economists were publishing reports with dire warnings, predicting overloads in the hospital system and huge spikes in deaths. The predicted catastrophe never came to be, however, and although the country faced some future waves, there was never a large spike in deaths despite its aging population, uninterrupted use of mass transportation, dense cities, and lack of a formal lockdown.It’s not that Japan was better situated than the United States in the beginning. Similar to the U.S. and Europe, Oshitani told me, Japan did not initially have the PCR capacity to do widespread testing. Nor could it impose a full lockdown or strict stay-at-home orders; even if that had been desirable, it would not have been legally possible in Japan.Oshitani told me that in Japan, they had noticed the overdispersion characteristics of COVID-19 as early as February, and thus created a strategy focusing mostly on cluster-busting, which tries to prevent one cluster from igniting another. Oshitani said he believes that “the chain of transmission cannot be sustained without a chain of clusters or a megacluster.” Japan thus carried out a cluster-busting approach, including undertaking aggressive backward tracing to uncover clusters. Japan also focused on ventilation, counseling its population to avoid places where the three C’s come together—crowds in closed spaces in close contact, especially if there’s talking or singing—bringing together the science of overdispersion with the recognition of airborne aerosol transmission, as well as presymptomatic and asymptomatic transmission.Oshitani contrasts the Japanese strategy, nailing almost every important feature of the pandemic early on, with the Western response, trying to eliminate the disease “one by one” when that’s not necessarily the main way it spreads. Indeed, Japan got its cases down, but kept up its vigilance: When the government started noticing an uptick in community cases, it initiated a state of emergency in April and tried hard to incentivize the kinds of businesses that could lead to super-spreading events, such as theaters, music venues, and sports stadiums, to close down temporarily. Now schools are back in session in person, and even stadiums are open—but without chanting.It’s not always the restrictiveness of the rules, but whether they target the right dangers. As Morris put it, “Japan’s commitment to ‘cluster-busting’ allowed it to achieve impressive mitigation with judiciously chosen restrictions. Countries that have ignored super-spreading have risked getting the worst of both worlds: burdensome restrictions that fail to achieve substantial mitigation. The U.K.’s recent decision to limit outdoor gatherings to six people while allowing pubs and bars to remain open is just one of many such examples.”Could we get back to a much more normal life by focusing on limiting the conditions for super-spreading events, aggressively engaging in cluster-busting, and deploying cheap, rapid mass tests—that is, once we get our case numbers down to low enough numbers to carry out such a strategy? (Many places with low community transmission could start immediately.) Once we look for and see the forest, it becomes easier to find our way out.”* This article originally stated that, in April, coronavirus deaths spiked in Quito, Ecuador. In fact, they spiked in Guayaquil, Ecuador.ZEYNEP TUFEKCI is a contributing writer at The Atlantic and an associate professor at the University of North Carolina. She studies the interaction between digital technology, artificial intelligence, and society.This Overlooked Variable Is the Key to the PandemicBUT BUT BUT ???SHARE18 hours agoJapan Declares State of Emergency in Tokyo Region to Counter Virus SurgeBy Alastair GalePeople wearing face masks cross an intersection in the Shinjuku neighborhood of Tokyo on Thursday.HIRO KOMAE/ASSOCIATED PRESSTOKYO—Japan’s prime minister declared a state of emergency in Tokyo and surrounding areas in an attempt to reverse an acceleration of Covid-19 infections.Yoshihide Suga said that people in the region should stay home after 8 p.m. and restaurants and bars should close by then from Friday for at least a month. New infections in Tokyo rose to 2,447 on Thursday, up sharply from the previous high of 1,591 a day earlier.“We’re in a situation that could have a very severe impact on people’s lives and the economy,” Mr. Suga said in nationally televised remarks.Japan has avoided hard lockdowns in its attempts to control the spread of the virus, and the emergency declaration isn’t backed by fines or other legal penalties. Virus cases declined during a similar emergency period last spring.Unlike during the previous emergency, schools won’t be required to close and events such as sports will be allowed to continue with some spectators. Mr. Suga has been cautious about imposing stricter controls because of the damage to the economy.Japan has focused its efforts on trying to reduce the spread of the virus among those socializing in the evening. Restaurants that cooperate with the new guidelines will receive around $580 per day in support from the government.The governors of Tokyo and surrounding areas called on Mr. Suga to declare the emergency as hospitals in the region struggle to cope with the new wave of infections.Mr. Suga said the emergency period would run until Feb. 7. However, some members of a panel of experts that advises the government on handling the pandemic say the state of emergency may need to stay in place for several months.Japan Declares State of Emergency in Tokyo Region to Counter Virus Surge - WSJ.comMISINFORMATION FROM MISUSE OF STATISTICSChris Martz@ChrisMartzWXCOVID-19 case numbers couldn’t be a more meaningless statistic, yet it’s the center of policy and drives fear. The only way to determine if cases are increasing is to compare the number of tests. When done so, nothing alarming. It’s time to end this sh*tshow and return to normal.1:28 PM · Dec 27, 2020Twitter for iPhoneDoctors urge local approach, not sweeping lockdown, in letter to Ford“The doctors argue against a wholesale return to a lockdown as a way to deal with rising COVID-19 cases.Special to Toronto SunOctober 1, 2020A stethoscope around a doctor's neck. STOCK PHOTO / GETTY IMAGESThe following letter, signed by 20 doctors and professors of medicine from faculties at the University of Toronto, McMaster University, University of Ottawa and from hospitals such as Sick Kids, was sent to Premier Doug Ford on Sept. 27. The doctors argue against a wholesale return to a lockdown as a way to deal with rising COVID-19 cases.Dear Premier Ford,We are writing this letter in support of the government’s plan to use a tactical localized approach, rather than sweeping new lockdown measures, to deal with the increasing COVID case numbers in Ontario.Lockdowns have been shown not to eliminate the virus. While they slow the spread of the virus, this only lasts as long as the lockdown lasts. This creates a situation where there is no way to end the lockdown, and society cannot move forward in vitally important ways including in the health sector, the economy and other critically important instrumental goods including education, recreation, and healthy human social interactions.In Ontario, the increase in cases at this time are in people under 60 years of age who are unlikely to become very ill. At the peak of the pandemic in Ontario in mid-April, 56% of cases were in those over age 60. Now in September, only 14% of cases are in over 60 year olds.In Ontario and other parts of the world, such as the European Union, increasing case loads are not necessarily translating into unmanageable levels of hospitalizations and ICU admissions. This is not a result of a lag in reporting of severe and fatal cases. While we understand the concerns that these cases could spill into vulnerable communities, we also need to balance the actual risk.As the virus circulates at manageable levels within the community, we need to continue the gains we have made in the protection of the vulnerable in long-term care and retirement institutions, and continue to educate other people about their individual risk, so that they can observe appropriate protective measures.Lockdowns have costs that have, to this point, not been included in the consideration of further measures. A full accounting of the implications on health and well-being must be included in the models, and be brought forward for public debate. Hard data now exist showing the significant negative health effects shutting down society has caused. Overdoses have risen 40% in some jurisdictions. Extensive morbidity has been experienced by those whose surgery has been cancelled, and the ramifications for cancer patients whose diagnostic testing was delayed has yet to be determined.A huge concern is the implication of closure of schools, and the ongoing reluctance we have seen in the large urban centres of sending children back to the classroom due to safety concerns. Global data clearly now show that children have an extremely low risk of serious illness, but they are disproportionately harmed by precautions. Children’s rights to societal care, mental health support and education must be protected. This cannot be achieved with ongoing or rotating lockdown.The invitation and involvement of other health experts to advise the government’s response beside individuals in Public Health and Infectious Diseases in addition to leaders in the business, securities and arts communities is essential. We also call for increased open debate, in the public forum, that hears voices from outside the medical and public health communities, in order to consider all points of view from society.This is a fundamental principle upon which democratic societies are built. All stakeholders should have an equal right to participation in public discourse when it comes to setting such fundamental and sweeping societal interventions.All have the right to feel their voices have been heard, and moreover to ensure factual credible data is openly debated, in contrast to the personal and political slants that have had apparent significant impacts on the management of the virus to date.Our society has borne enormous pain over the past six months. It’s time to do something different.Sincerely,Jane Batt MD, PhD, FRCPC. Respirologist, Associate Professor, Department of Medicine, University of TorontoJames Bain MD, MSc, FRCSC. Plastic Surgeon, Professor of Surgery, McMaster UniversityMahin Baqi MD, FRCPC. Infection Prevention and Control and Infectious Diseases PhysicianMarcus Bernardini MD, FRCPC. Gynecologic Oncologist, Associate Professor, University of TorontoSergio Borgia MD, MSc, FRCPC. Infection Prevention and Control and Infectious Diseases Physician, Assistant Clinical Professor, McMaster UniversityPeter Cox, MBChB, FRCPC, DCH(SA), FFARCS. Critical Care Physician, Professor, Department of Anaesthesia, University of TorontoJames D. Douketis, MD, FRCPC, FCAHS. Haematologist, Professor of Medicine, McMaster UniversityPhilippe El-Helou, MD, FRCPC. Infectious Diseases Physician, Associate Professor, Department of Medicine, McMaster UniversityMartha Fulford MD, FRCPC. Infectious Diseases Physician, Associate Professor, Department of Medicine, McMaster UniversityShariq Haider MD, FRCPC. Infectious Diseases Physician, Professor, Department of Medicine, McMaster UniversityStephen Kravcik MD, FRCPC. General Internist, Associate Professor, Department of Medicine, University of OttawaNicole Le Saux MD, FRCPC. Infectious Diseases Physician, Professor, Department of Pediatrics, University of OttawaPaul MacPherson PhD, MD, FRCPC. Infectious Diseases Physician, Associate Professor, Department of Medicine, University of OttawaNeil Rau MD, FRCPC. Infectious Diseases Physician and Medical Microbiologist, Assistant Professor, Department of Medicine, University of TorontoSusan Richardson MD, FRCPC. Medical Microbiologist and Infectious Disease Physician, Professor Emerita, Department of Laboratory Medicine and Pathobiology, University of TorontoRob Sargeant MD, PhD, FRCPC. General Internist, Associate Professor, Department of Medicine, University of TorontoNick Vozoris MD, MHSc, FRCPC. Respirologist, Assistant Professor, Department of Medicine, University of TorontoThomas Warren MD, FRCPC. Infectious Diseases Physician and Medical Microbiologist, Assistant Clinical Professor (Adjunct), Department of Medicine, McMaster UniversityYvonne Yau, MD FRCPC. Medical Microbiologist, Assistant Professor, Department of Laboratory Medicine and Pathobiology, University of TorontoGeorge Yousef MD, PhD, FRCPC. Anatomic Pathologist, Professor, Department of Laboratory Medicine and Pathobiology, University of TorontoDr. Susan Richardson joined Anthony Furey on National Post Radio to explain why her and her colleagues believe Ontario shouldn’t go into a second lockdown and the best ways to tackle COVID-19: “Doctors urge local approach, not sweeping lockdown, in letter to FordCoronavirus and the homeless: Washington risks 'people dying in communal shelters'People without a home to self-quarantine in and without regular access to sanitation are likelier to contract the coronavirus. As cases hit New York City shelters, advocates in D.C. are warning about the city’s homeless.We have all heard what to do to minimize the risk of getting coronavirus: Wash your hands regularly, stay at home if possible, stay away from large crowds and keep a safe distance. But what if your home is a tent without running water? Or if you can only get a warm meal and a roof over your head in a shelter where the beds are packed together in cramped quarters? This is the difficult reality facing homeless people.In 2019, the Washington, D.C. metropolitan area had roughly 9,800 homeless residents, according to a study by the Metropolitan Washington Council of Governments. The number fluctuates greatly and cannot be pinned down exactly. One thing is certain, however: a large number of people without a roof over their heads are facing even greater challenges since the coronavirus outbreak.The US organization National Alliance to End Homelessness states on their website that "individuals experiencing homelessness include many older adults, often with compounding disabilities, who reside in large congregate facilities or in unsheltered locations with poor access to sanitation." The coronavirus entry continues: "Their age, poor health, disability, and living conditions make them highly vulnerable to illness."Coronavirus and the homeless: Washington risks 'people dying in communal shelters' | DW | 21.03.2020A closer look at U.S. deaths due to COVID-19By YANNI GU | November 22, 2020COURTESY OF GENEVIEVE BRIANDAfter retrieving data on the CDC website, Briand compiled a graph representing percentages of total deaths per age category from early February to early September.According to new data, the U.S. currently ranks first in total COVID-19 cases, new cases per day and deaths. Genevieve Briand, assistant program director of the Applied Economics master’s degree program at Hopkins, critically analyzed the effect of COVID-19 on U.S. deaths using data from the Centers for Disease Control and Prevention (CDC) in her webinar titled “COVID-19 Deaths: A Look at U.S. Data.”From mid-March to mid-September, U.S. total deaths have reached 1.7 million, of which 200,000, or 12% of total deaths, are COVID-19-related. Instead of looking directly at COVID-19 deaths, Briand focused on total deaths per age group and per cause of death in the U.S. and used this information to shed light on the effects of COVID-19.She explained that the significance of COVID-19 on U.S. deaths can be fully understood only through comparison to the number of total deaths in the United States.After retrieving data on the CDC website, Briand compiled a graph representing percentages of total deaths per age category from early February to early September, which includes the period from before COVID-19 was detected in the U.S. to after infection rates soared.Surprisingly, the deaths of older people stayed the same before and after COVID-19. Since COVID-19 mainly affects the elderly, experts expected an increase in the percentage of deaths in older age groups. However, this increase is not seen from the CDC data. In fact, the percentages of deaths among all age groups remain relatively the same.“The reason we have a higher number of reported COVID-19 deaths among older individuals than younger individuals is simply because every day in the U.S. older individuals die in higher numbers than younger individuals,” Briand said.Briand also noted that 50,000 to 70,000 deaths are seen both before and after COVID-19, indicating that this number of deaths was normal long before COVID-19 emerged. Therefore, according to Briand, not only has COVID-19 had no effect on the percentage of deaths of older people, but it has also not increased the total number of deaths.These data analyses suggest that in contrast to most people’s assumptions, the number of deaths by COVID-19 is not alarming. In fact, it has relatively no effect on deaths in the United States.This comes as a shock to many people. How is it that the data lie so far from our perception?To answer that question, Briand shifted her focus to the deaths per causes ranging from 2014 to 2020. There is a sudden increase in deaths in 2020 due to COVID-19. This is no surprise because COVID-19 emerged in the U.S. in early 2020, and thus COVID-19-related deaths increased drastically afterward.Analysis of deaths per cause in 2018 revealed that the pattern of seasonal increase in the total number of deaths is a result of the rise in deaths by all causes, with the top three being heart disease, respiratory diseases, influenza and pneumonia.“This is true every year. Every year in the U.S. when we observe the seasonal ups and downs, we have an increase of deaths due to all causes,” Briand pointed out.When Briand looked at the 2020 data during that seasonal period, COVID-19-related deaths exceeded deaths from heart diseases. This was highly unusual since heart disease has always prevailed as the leading cause of deaths. However, when taking a closer look at the death numbers, she noted something strange. As Briand compared the number of deaths per cause during that period in 2020 to 2018, she noticed that instead of the expected drastic increase across all causes, there was a significant decrease in deaths due to heart disease. Even more surprising, as seen in the graph below, this sudden decline in deaths is observed for all other causes.COURTESY OF GENEVIEVE BRIANDGraph depicts the number of deaths per cause during that period in 2020 to 2018.This trend is completely contrary to the pattern observed in all previous years. Interestingly, as depicted in the table below, the total decrease in deaths by other causes almost exactly equals the increase in deaths by COVID-19. This suggests, according to Briand, that the COVID-19 death toll is misleading. Briand believes that deaths due to heart diseases, respiratory diseases, influenza and pneumonia may instead be recategorized as being due to COVID-19.COURTESY OF GENEVIEVE BRIANDGraph depicts the total decrease in deaths by various causes, including COVID-19.The CDC classified all deaths that are related to COVID-19 simply as COVID-19 deaths. Even patients dying from other underlying diseases but are infected with COVID-19 count as COVID-19 deaths. This is likely the main explanation as to why COVID-19 deaths drastically increased while deaths by all other diseases experienced a significant decrease.“All of this points to no evidence that COVID-19 created any excess deaths. Total death numbers are not above normal death numbers. We found no evidence to the contrary,” Briand concluded.In an interview with The News-Letter, Briand addressed the question of whether COVID-19 deaths can be called misleading since the infection might have exacerbated and even led to deaths by other underlying diseases.“If [the COVID-19 death toll] was not misleading at all, what we should have observed is an increased number of heart attacks and increased COVID-19 numbers. But a decreased number of heart attacks and all the other death causes doesn’t give us a choice but to point to some misclassification,” Briand replied.In other words, the effect of COVID-19 on deaths in the U.S. is considered problematic only when it increases the total number of deaths or the true death burden by a significant amount in addition to the expected deaths by other causes. Since the crude number of total deaths by all causes before and after COVID-19 has stayed the same, one can hardly say, in Briand’s view, that COVID-19 deaths are concerning.Briand also mentioned that more research and data are needed to truly decipher the effect of COVID-19 on deaths in the United States.Throughout the talk, Briand constantly emphasized that although COVID-19 is a serious national and global problem, she also stressed that society should never lose focus of the bigger picture — death in general.The death of a loved one, from COVID-19 or from other causes, is always tragic, Briand explained. Each life is equally important and we should be reminded that even during a global pandemic we should not forget about the tragic loss of lives from other causes.According to Briand, the over-exaggeration of the COVID-19 death number may be due to the constant emphasis on COVID-19-related deaths and the habitual overlooking of deaths by other natural causes in society.During an interview with The News-Letter after the event, Poorna Dharmasena, a master’s candidate in Applied Economics, expressed his opinion about Briand’s concluding remarks.“At the end of the day, it’s still a deadly virus. And over-exaggeration or not, to a certain degree, is irrelevant,” Dharmasena said.When asked whether the public should be informed about this exaggeration in death numbers, Dharmasena stated that people have a right to know the truth. However, COVID-19 should still continuously be treated as a deadly disease to safeguard the vulnerable population.A closer look at U.S. deaths due to COVID-19The coronavirus doesn’t exist in isolation — it feeds on other diseases, crisesMay 25, 2020 11.04am EDTAuthor“1. We may be in self-isolation, but the COVID-19 pandemic is clearly not.It isn’t isolated from other social, environmental and health crises — like food insecurity, the opioid crisis and the mental health crisis — nor is it separate from other epidemics like HIV, malaria, dengue fever and Zika virus.When two or more epidemics co-exist and compound one another to worsen health, they are said to be syndemic, or “synergistic epidemics.”What is a syndemic?The concept of syndemics arose in the 1990s to describe how substance abuse, violence and AIDS (known as the SAVA syndemic) overlapped and negatively reinforced health among inner-city populations in the United States.The concept has been cited increasingly over the past 25 years to call attention to the way various diseases like HIV and tuberculosis, along with mental illness, diabetes and infectious diseases cluster together, particularly in disadvantaged populations.While the term syndemic has traditionally been used to describe disease clusters at the individual level, a 2019 Lancet Commission study expanded on the concept to include climate change.The commission called the clustering of climate change and malnutrition (including both obesity and undernutrition) the Global Syndemic. This is because they share common underlying societal causes, such as modern industrial food systems, and affect people in all corners of the world.Dr. Horacio Arruda, Québec’s, director of health, reminds people to keep their distance as he arrives for a visit to a day centre for the homeless on May 8, 2020 in Montréal. THE CANADIAN PRESS/Ryan RemiorzA key feature of a syndemic is the way overlapping diseases and health conditions amplify one another biologically within the human body. For example, a disease can weaken the immune system and promote the progression of another disease.Interactions between overlapping diseases and other health conditions can complicate medical treatments, lead to higher health-care costs and worsen health outcomes. In the case of COVID-19, people with pre-existing and underlying conditions, including obesity, high blood pressure and diabetes, appear to be at higher risk for complications from the disease.But diseases don’t just interact biologically, they also interact with social factors. Poverty, housing, education and social stigma, for example, are all powerful determinants of health.Individuals with lower incomes and less education are several times more likely to develop diabetes than more socially advantaged individuals. These same relationships play a part in other risk factors for COVID-19, like high blood pressure and obesity.And it’s precisely these interactions — between both biological and social factors — that sets syndemics apart from other epidemic events.COVID-19 and marginalized communitiesThe coronavirus has been particularly dangerous for marginalized and vulnerable populations.A major outbreak of COVID-19 in the Navajo Nation is one example. Many Navajo people have underlying health conditions and lack basic needs, including access to running water.A Navajo mother and daughter sit on their family’s compound in Tuba City, Ariz., on April 20, 2020. The Navajo reservation has some of the highest rates of coronavirus in the United States. (AP Photo/Carolyn Kaster)By regarding COVID-19 as a syndemic and taking biological and social interactions directly into account, health practitioners could become more effective in their clinical practices and community-based interventions — in the United States, Canada and around the world.Addressing a syndemic demands not only the management of each affliction, but efforts to address the underlying forces that unite them — social inequality chief among them.In Canada, we have seen some semblance of this approach in COVID-19 emergency response strategies directed towards supporting people experiencing homelessness and violence and food banks and local food organizations.Yet these responses don’t go far enough. A basic income, not just expanded food charity, is needed to address food insecurity.Read more: More than food banks are needed to feed the hungry during the coronavirus pandemicWithout strong national frameworks to protect fundamental human rights (like access to food and housing), the ability of Canadians to meet their most basic needs, including health care, is vulnerable to the vagaries of government funding decisions and political will.In 2018, for example, a pilot project in Ontario to implement basic income in Ontario was cut by the incoming government.‘Slow-motion disaster’Most of the social and health issues now at the forefront of the COVID-19 pandemic were already major public health concerns prior to the outbreak of the pandemic.But these issues were often long term in nature. For example, rates of non-communicable disease — those not transmissible directly from one person to another, like type 2 diabetes and cardiovascular disease — have been surging for decades into what the World Health Organization (WHO) has called a “slow-motion disaster.” Yet immediate emergencies are dealt with first, while long-term problems wait.And as they tended to disproportionately impact socially, economically and politically marginalized groups, funding and responses have been inadequate. A lack of funding, for example, is responsible for the stalled progress on the eradication of tuberculosis in Inuit communities.Living conditions in Indigenous communities have long been inadequate, but the lack of access to clean water and a housing crisis persist.So why are governments only responding now? Could these issues not have been responded to sooner? Far more money, in fact, is spent responding to health crises than preparing and preventing them.Leaving no one behindThe WHO suggests an all-hazards approach to preparedness, from infectious disease outbreaks to extreme weather events and climate change. Epidemics, in fact, were only one of 13 urgent global health challenges identified for the next decade by the WHO in January.What the COVID-19 pandemic makes clear is that we need an “all people approach” that leaves no one behind, wherein the social factors and health conditions that cluster around the most vulnerable are not ignored until they’re cast to the foreground of a global pandemic.A man rides his ATV in the northern Ontario First Nations reserve in Attawapiskat, Ont., in April 2016. THE CANADIAN PRESS/Nathan DenetteThinking about COVID-19 through a syndemics lens helps bring attention to the fact that these crises haven’t waned, and they aren’t background noise.Instead, they’re compounded to forge a challenging landscape within which the COVID-19 pandemic has now taken centre stage. The health and social issues that concentrate in disadvantaged populations, and/or that are chronic and long-term in nature, simply can’t wait any longer.”https://theconversation.com/the-coronavirus-doesnt-exist-in-isolation-it-feeds-on-other-diseases-crises-135664The syndemic rewards countries like Canada with better health from fewer NCD or non communicable diseases like obesity and diabetes.Does Canada’s obesity data being lower than the USA matter?“Obesity has been described as a global epidemic. It has been linked to diabetes, hypertension, cardiovascular disease and some forms of cancer. Accurate surveillance of obesity trends is an important step in developing effective strategies to reduce its impact on public health. In the United States, the National Health and Nutrition Examination Survey (NHANES) has been gathering measured height and weight data for years. In 2007, the Canadian Health Measures Survey (CHMS), the most comprehensive health measures survey in Canada, began collecting direct measurements of height, weight, body mass index (BMI), skinfolds and waist circumference from a nationally representative sample of the population. The complementary nature of these surveys has created an opportunity to compare rates of obesity among adults in Canada and the United States.In 2007 to 2009, the prevalence of obesity in Canada was 24.1%, over 10 percentage points lower than in the United States (34.4%).Among men, the prevalence of obesity was over 8 percentage points lower in Canada than in the United States (24.3% compared with 32.6%) and among women, more than 12 percentage points lower (23.9% compared with 36.2%) (Chart 1).”Chart 1Prevalence of obesity in adults aged 20 to 79, by sex: Canada, 2007 to 2009 and United States, 2007 to 2008DescriptionBecause Sweden now has Europe’s lowest death rate herd immunity is seen as one explanation although not very convincing. It seems rather than Sweden treated the virus as syndemic where the focus was on the comorbidity not testing and masks etc. Sweden did put strong protections for the elderly and vulnerable pollutions who would well be the most likely to have NCDs but allowed the younger populations to go about their business. See this CNN video below-WUHAN VIRUSNEWSArticlesDR. ROGER HODKINSON ON COVID: “THIS IS THE BIGGEST HOAX EVER PERPETRATED ON AN UNSUSPECTING PUBLIC”NOVEMBER 18, 2020 CAP ALLON“Dr. Roger Hodkinson is the former Chairman of the Royal College of Physicians and Surgeons committee in Ottawa, he was once CEO of a large private medical laboratory in Edmonton, Alberta, and for the past 20 years has held the position as Chairman of a Medical Biotechnology company based in North Carolina currently tasked with selling a COVID-19 test. He is a medical specialist in pathology, which includes virology, who trained at Cambridge University in the UK — he is perfectly positioned to speak on this topic.In a recent Edmonton City Council Community and Public Services Committee meeting (the audio from which is currently gaining traction on YouTube), Dr. Hodkinson says: “The bottom line is there is utterly unfounded public hysteria driven by the media and politicians. It’s outrageous. This is the greatest hoax ever perpetrated on an unsuspecting public.“[COVID-19] is nothing more than a bad flu season. This is not Ebola. It’s not SARS. It’s politics playing medicine, and that’s a very dangerous game.”Hodkinson goes on to stress that no action of any kind is needed, other than what happened during last year’s flu season: “If we felt ill, we stayed home, we took chicken noodle soup, we didn’t visit granny, we decided when we would return to work; we didn’t need anyone to tell us.”“MASK ARE UTTERLY USELESS”“There is no evidence base for their effectiveness whatsoever.“[Masks] are simply virtue signalling.“Seeing these people walking around like lemmings obeying, without any knowledge base, to put the mask on their face.”“SOCIAL DISTANCING IS ALSO USELESS”“COVID is spread by aerosols, which travel 30 meters-or-so before landing.”“CLOSURES OF SCHOOLS AND BUSINESSES HAVE HAD SUCH TERRIBLE CONSEQUENCES”“Everywhere should be open tomorrow, as was stated in the Great Barrington Declaration (linked below).“POSITIVE TEST RESULTS DO NOT MEAN A CLINICAL INFECTION”“All testing should stop, unless you’re presenting to hospital with some respiratory problem … it’s driving public hysteria, and all testing should stop.“All that should be done is to protect the vulnerable.“And I would remind you all that using the provinces [Alberta’s] own statistics, the risk of death under 65 is 1 in 300,000. You’ve got to get a grip on this. The scale of the response … with no evidence for it, is utterly ridiculous.“Suicides, business closures, [cancelled] funerals, weddings, etc., etc. — it’s simply outrageous, it’s just another bad flu, and [people] have got to get their minds around that.”Hodkison concludes with some advice for policy makers in Alberta: “Let people make their own decisions. You should be totally out of the business of medicine. You’re being led down the garden path by the chief medical officer of health in this province. I’m absolutely outraged that this has reached this level. It should all stop tomorrow. Thank you very much.”Dr. Roger Hodkinson on COVID: "This is the Biggest Hoax ever perpetrated on an Unsuspecting Public" - ElectroverseI Am Living in a Covid-Free World Just a Few Hundred Miles From ManhattanWelcome to Nova Scotia, the land that proves that beating back the virus is possible.By Stephanie NolenMs. Nolen is a journalist.Nov. 18, 2020760Credit...Paul Atwood for The New York Times“HALIFAX, Nova Scotia — This morning, my children went to school — school, in an old brick building, where they lined up to go in the scuffed front doors. I went to work out at the gym, the real gym, where I huffed and puffed in a sweaty group class. And a few days ago, my partner and I hosted a dinner party, gathering eight friends around the dining room table for a boisterous night that went too late. Remember those?Where I’m living, we gather without fear. Life is unfolding much as it did a year ago. This magical, virus-free world is just one long day’s drive away from the Empire State Building — in a parallel dimension called Nova Scotia.This is one of the four Atlantic provinces that cling to the coast of Canada, north and east of Maine. In Canada, these are typically known as “have-not provinces,” economically depressed areas dependent on cash transfers from wealthier provinces to the West.In the pandemic era, however, “have not” takes on new meaning.ImageCredit...Paul Atwood for The New York TimesImageOur coronavirus lockdown began swiftly in March and was all-encompassing. The provincial borders were slammed shut. In Nova Scotia, even public hiking trails were closed, a big deal for a population used to the freedom to head into the wilderness at will. But the lockdown worked, and we released our collectively held breath as new case numbers dropped to the single digits. Restrictions eased in May and lifted in June; in early July, the Atlantic provinces “bubbled” together, allowing free travel among them — but maintaining a strict quarantine rule for anyone who came from outside. And the border to the south, the one with the United States, has remained firmly closed.Credit...Paul Atwood for The New York TimesThe horrific pandemic news from south of the border feels like a looming shadow these days. The numbers coming from the United States are almost ungraspable: 120,000, 140,000, 180,000 new cases a day. When I talk to friends there, they are locked up in their houses, trying to work with the kids running through the room, or, increasingly often, sick or recovering from Covid-19. Case counts are also climbing in other parts of Canada. My brother and his family in Montreal are once again in lockdown. The pictures I post in our group chat, of slumber parties and speedskating races, are a surreal contrast to their circumscribed days.The pandemic has changed the way people live, here, too. We stand six feet apart in the line at the grocery store. There is plexiglass around the cashier at Starbucks. I had to keep my dinner party guest list to 10 people in total. Nova Scotia has required everyone to wear a mask in any indoor public space, including upper grade schools, since July. But that seems normal, by now, just one more thing in the morning: got your homework, got your lunch, got your mask? I can go days without the virus really intruding on my life.And word has gotten out: The Halifax real-estate market is frenzied this fall. Our small, pretty city has relatively affordable housing, beaches and wooded parks. But historically a lack of jobs kept ambitious people away. Now that so many of us work from the kitchen table, the pokey economy matters much less — and Torontonians are fleeing the big city, and the virus, for a charmed life in the bubble.”Editors’ PicksWhen It Comes to Living With Uncertainty, Michael J. Fox Is a ProKurt Russell and Goldie Hawn, a.k.a. Mr. and Mrs. ClausThe Thanksgiving Myth Gets a Deeper Look This YearContinue reading the main storyContinue reading the main storyImageCredit...Paul Atwood for The New York TimesGeography and demographics have helped Atlantic Canada establish this alternate universe. The population is small, about 2.5 million people across the region, none of it too densely populated. Newfoundland and Prince Edward Island are, well, islands, which makes border control easier. Only one province in this bubble has a land border with the United States, and only one an active border with Quebec, the hardest-hit province. The Halifax airport is the largest in the region, and it was receiving only about a dozen international flights each day when the pandemic began. There are none now. We’re a very small New Zealand.When I asked Robert Strang, Nova Scotia’s avuncular public health chief, what he thought allowed us to maintain this level of normality, he added another ingredient to my list: Public health officials, not politicians, set the policy here about what opens. And people (mostly) follow the rules on closures and gatherings and masks. “The message has been that we need to do it to keep each other safe,” he told me. “I think there’s something about our culture, our collective ethic, if you will, that means people accept that.”The pandemic has caused real pain in this region: the economy, heavily dependent on tourism, has regained only about 80 percent of the jobs that were lost in April, and won’t fully recover with the borders closed. This morning I saw another small business in my neighborhood with a closing-down notice taped to a shuttered window. Eviction rates are climbing. Residents of long-term care homes can have only limited visitors. If we leave the region, we have to spend two weeks in quarantine when we come back, and that can make a person feel trapped.We argue all the time about what level of isolation and restriction are appropriate; but we have a sense here in Halifax of what has kept us safe and we know that those things are deeply controversial in the United States: public health care; public media; a social safety net. It’s baffling to watch the epidemic in the United States spin wildly out of control, knowing it could easily be different. We know that it could, because we’re living it.At my dinner party last week, my friends and I raised a glass to our good fortune, and to Dr. Strang. Our freedom feels precious and fragile. It has not come cheap. But it’s a steadying thing, the knowledge that we will make hard choices for each other, and that sometimes when we do, the reward is a life we recognize.Stephanie Nolen is a journalist based in Halifax, Nova Scotia.ESPECIALLY RELEVANT TODAY THAT THE NCD COUNTRY % RANKING FOR DIABETES SHOWS US IS MUCH HIGHER THAN CANADA AT 10.8 TO 7.6 WHILE SWEDEN IS ONLY 4.8.Home > Indicators > Health > Risk factorsDiabetes prevalence (% of population ages 20 to 79) - Country Ranking - North AmericaDefinition: Diabetes prevalence refers to the percentage of people ages 20-79 who have type 1 or type 2 diabetes.Source: International Diabetes Federation, Diabetes Atlas.See also: Thematic map, Time series comparisonFind indicator:Rank Country Value Year 20191 Mexico 13.502 United States 10.803 Canada 7.604 Greenland 2.10Why people with diabetes are being hit so hard by Covid-19By ELIZABETH COONEY @cooney_lizOCTOBER 1, 2020There are no easy answers to the coronavirus pandemic, but for people with diabetes, it’s dismayingly difficult to untangle the thicket of biological and socioeconomic factors that make them more likely to suffer severe illness and die should they catch the virus that causes Covid-19. That leaves prevention — controlling blood sugar through diet, exercise, monitoring, and medication — as the leading tactic to protect people, until a successful vaccine proven to work in people with diabetes, too, reaches a population bearing multiple burdens of chronic illness.The numbers are alarming. A Lancet Diabetes & Endocrinology study mining 61 million medical records in the U.K. says 30% of Covid-19 deaths occurred in people with diabetes. After accounting for potentially relevant risk factors such as social deprivation, ethnicity, and other chronic medical conditions, the risk of dying from Covid-19 was still almost three times higher for people with type 1 diabetes and almost twice as high for type 2, versus those without diabetes.Data from the U.S. Centers for Disease Control and Prevention show more than three-quarters of people who died from Covid-19 had at least one preexisting condition. Overall, diabetes was noted as an underlying condition for approximately 4 in 10 patients. Among people younger than 65 who died from the infection, about half had diabetes.Why people with diabetes are being hit so hard by Covid-19Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide AnalysisWei-jie Guan, Wen-hua Liang, Yi Zhao, Heng-rui Liang, Zi-sheng Chen, Yi-min Li, Xiao-qing Liu, Ru-chong Chen, Chun-li Tang, Tao Wang, Chun-quan Ou, Li Li, Ping-yan Chen, Ling Sang, Wei Wang, Jian-fu Li, Cai-chen Li, Li-min Ou, Bo Cheng, Shan Xiong, Zheng-yi Ni, Jie Xiang, Yu Hu, Lei Liu, Hong Shan, Chun-liang Lei, Yi-xiang Peng, Li Wei, Yong Liu, Ya-hua Hu, Peng Peng, Jian-ming Wang, Ji-yang Liu, Zhong Chen, Gang Li, Zhi-jian Zheng, Shao-qin Qiu, Jie Luo, Chang-jiang Ye, Shao-yong Zhu, Lin-ling Cheng, Feng Ye, Shi-yue Li, Jin-ping Zheng, Nuo-fu Zhang, Nan-shan Zhong, Jian-xing He on behalf of China Medical Treatment Expert Group for Covid-19European Respiratory Journal 2020; DOI: 10.1183/13993003.00547-2020ArticleFigures & DataInfo & MetricsPDFAbstractBackground The coronavirus disease 2019 (Covid-19) outbreak is evolving rapidly worldwide.Objective To evaluate the risk of serious adverse outcomes in patients with coronavirus disease 2019 (Covid-19) by stratifying the comorbidity status.Methods We analysed the data from 1590 laboratory-confirmed hospitalised patients 575 hospitals in 31 province/autonomous regions/provincial municipalities across mainland China between December 11th, 2019 and January 31st, 2020. We analyse the composite endpoints, which consisted of admission to intensive care unit, or invasive ventilation, or death. The risk of reaching to the composite endpoints was compared according to the presence and number of comorbidities.Results The mean age was 48.9 years. 686 patients (42.7%) were females. Severe cases accounted for 16.0% of the study population. 131 (8.2%) patients reached to the composite endpoints. 399 (25.1%) reported having at least one comorbidity. The most prevalent comorbidity was hypertension (16.9%), followed by diabetes (8.2%). 130 (8.2%) patients reported having two or more comorbidities. After adjusting for age and smoking status, COPD [hazards ratio (HR) 2.681, 95% confidence interval (95%CI) 1.424–5.048], diabetes (HR 1.59, 95%CI 1.03–2.45), hypertension (HR 1.58, 95%CI 1.07–2.32) and malignancy (HR 3.50, 95%CI 1.60–7.64) were risk factors of reaching to the composite endpoints. The HR was 1.79 (95%CI 1.16–2.77) among patients with at least one comorbidity and 2.59 (95%CI 1.61–4.17) among patients with two or more comorbidities.Conclusion Among laboratory-confirmed cases of Covid-19, patients with any comorbidity yielded poorer clinical outcomes than those without. A greater number of comorbidities also correlated with poorer clinical outcomesComorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide AnalysisAbstractBackground:In this study, we aimed to assess the prevalence of comorbidities in the confirmed COVID-19 patients. This might help showing which comorbidity might pose the patients at risk of more severe symptoms.Methods:We searched all relevant databases on April 7th, 2020 using the keywords (“novel coronavirus” OR COVID-19 OR SARS-CoV-2 OR Coronavirus) AND (comorbidities OR clinical characteristics OR epidemiologic*). We reviewed 33 papers’ full text out of 1053 papers. There were 32 papers from China and 1 from Taiwan. There was no language or study level limit. Prevalence of comorbidities including hypertension, diabetes mellitus, cardiovascular disease, chronic lung disease, chronic kidney disease, malignancies, cerebrovascular diseases, chronic liver disease and smoking were extracted to measure the pooled estimates. We used OpenMeta and used random-effect model to do a single arm meta-analysis.Results:The mean age of the diagnosed patients was 51 years. The male to female ratio was 55 to 45. The most prevalent finding in the confirmed COVID-19 patients was hypertension, which was found in 1/5 of the patients (21%). Other most prevalent finding was diabetes mellitus (DM) in 11%, cerebrovascular disease in 2.4%, cardiovascular disease in 5.8%, chronic kidney disease in 3.6%, chronic liver disease in 2.9%, chronic pulmonary disease in 2.0%, malignancy in 2.7%, and smoking in 8.7% of the patients.Conclusion:COVID-19 infection seems to be affecting every race, sex, age, irrespective of health status. The risk of symptomatic and severe disease might be higher due to the higher age which is usually accompanied with comorbidities. However, comorbidities do not seem to be the prerequisite for symptomatic and severe COVID-19 infection, except hypertension.Prevalence of Comorbidities in COVID-19 Patients: A Systematic Review and Meta-Analysis“Contrast Between New York And Florida”December 22, 2020/ Francis Menton“Of all the states, the one most comparable to New York by demographics is Florida. These two states are close not only in overall population, but also in relative numbers of immigrants and of minority groups. As to population, as recently as 2013, New York had slightly more population than Florida (both around 19.6 million), but since then Florida has been growing rapidly, while New York has been shrinking slowly. Pending release of final 2020 Census numbers, estimates put Florida’s current population at about 21.8 million, and New York’s at about 19.4 million.Despite being, at least for now, relatively close in population and other demographics, New York and Florida could not be more different in their approaches to public policy. In Florida, Republicans have controlled the legislature (both houses) since 1997, and the governorship since 1999. Florida exemplifies the low tax, low spend, low regulation approach to state government. New York is firmly in control of the progressive left, and exemplifies high taxes, high spending, and high regulation.Different policies lead to different results. For today I’ll focus mainly on the policy response to the Covid-19 virus. On this subject, the differences in policy mostly concern regulation, rather than taxing and spending.Yesterday, I had a roundup of the current onerous regulatory response to the virus in New York. By contrast, Florida, led by Republican Governor Ron DeSantis, has been very much at the opposite end of the regulatory response spectrum. As to results, here’s the bottom line: As one would expect, the economic decline caused by intentional government suppression of the economy has been much, much less severe in Florida than New York; but just as important, Florida has also experienced, and continues to experience, superior health results to New York. In other words, Florida stands as a clear demonstration that all of New York’s behavioral mandates (e.g., masks) and intentional destruction of small business have had no measurable effect whatsoever in decreasing spread of the virus or in improving health results.As per my review yesterday, in New York City, restaurant dining has been severely restricted for months under fluctuating directives, and as of last week, by order of the Governor, all indoor restaurant dining has been shut down entirely, with no indication of when it may re-open. Theaters, concerts and performance venues are all shuttered, and it appears they will remain so at least until the Spring. Although not mentioned in yesterday’s post, since April 17 we have had a state-wide mandate for mask-wearing covering “anyone over the age of 2” when “in a public place.”Florida at first imposed some substantial restrictions on restaurants and other indoor businesses, but began loosening them in early June, when, for example, bars and movie theaters were allowed to reopen. On September 28 Governor DeSantis issued an executive order rescinding almost all of the remaining restrictions. At a news briefing that day, DeSantis was quoted as saying “Every business has the right to operate,” and “We’re not closing anything going forward.” WebMD summarized Florida’s provisions going forward from that time:Businesses that have used remote work protocols can return to unrestricted staffing at their offices. Employees can resume non-essential travel. Theme parks can return to normal operations, and gyms can operate at full capacity. Bars and clubs can operate at full capacity but with “limited social distancing protocols.”In Florida today, theaters are open, concerts are happening, and the iconic theme parks are accepting visitors (if on a somewhat restricted basis).As to masks, Florida never imposed a state-wide mandate, but instead left it up to each county to make its own decision. Twenty-two counties imposed mask mandates for at least some period of time, but 45 never did. Townhall on December 21 has a long piece (mostly based on a paywalled study of the data at Rational Ground) giving the results. Those results are totally devastating to any claim of effectiveness of mask mandates. From Town Hall (with internal quote from Rational Ground):If masks did even close to as advertised, one would expect to see the counties that went maskless to be absolute dumpster fires next to the counties that implemented mandates, right? At the very least, the numbers should favor the masked areas by more than a percentage point or two. So, how did it go? Yep, it was the Mask Cult’s worse nightmare: “When counties DID have a mandate in effect, there were 667,239 cases over 3,137 days with an average of 23 cases per 100,000 per day. When counties DID NOT have a countywide order, there were 438,687 cases over 12,139 days with an average of 22 cases per 100,000 per day.”In short, the mask-free counties actually had better health results than the counties with mask mandates.As part of his September 28 directives, Governor DeSantis announced that he would not enforce any fines or penalties for failure to wear masks.So let’s compare health and economic results as between Florida and New York. First, health:Florida. Deaths per million population, pandemic inception to date (figures from Worldometers.info as of December 22): 966. Deaths within last 10 days, most recent first, from Dec 21 back to Dec 12: 106, 86, 69, 108, 102, 112, 89, 137, 81, 71 — total of 961 over that 10 day period.New York. Deaths per million population, pandemic inception to date: 1,886 (almost double Florida’s rate — and Florida has far more elderly people). Deaths within last 10 days, most recent first from Dec 21 to Dec 12: 179, 95, 85, 121, 156, 112, 126, 120, 87, 79 — total of 1160 over the ten days, or more than 20% more than Florida, even though Florida has more than 10% more population.If New York’s elected leaders have anything to show for turning this city into a ghost town, you sure can’t find it in those statistics.Now, as to economic statistics:Florida. Unemployment rate for November (most recent available): 6.4% (versus national rate of 6.7%)New York. Unemployment rate for New York State for November: 8.4%; for New York City, 12.1%. Clearly, New York City is bearing the brunt of the forced closures of the restaurant and entertainment industries.For New York City, that extra almost 6% people unemployed by forced government action, as compared to Florida, represents about 200,000 people, most of them from the lower end of the income distribution. I suppose you could kind of, sort of justify intentionally putting all those people out of work if you could show some kind of health benefit from the decrees. But there is no health benefit to be shown. New York’s health results are demonstrably worse than those of Florida. The virus does its own thing, despite our dictators’ desperate need to show that they are “doing something,” however meaningless the “something” may be.In other comparisons of public policy metrics between the two states, Florida’s annual state government budget is about $92 billion, while New York’s is $177 billion. How could that possibly be, when Florida has 10% more people? New York City spends almost $29,000 per student on K-12 education, while Florida spends less than $10,000 — and Florida gets somewhat better results on the NAEP national tests. And of course, New York has some of the highest income tax rates in the country, and yet has a legislature desperate to raise more revenue by hiking rates even higher; while Florida has no income tax at all and yet seems to have sufficient money to go around.Florida shows us all what basic competent state government looks like. The extreme lack of competence in New York is simply shocking.Contrast Between New York And Florida — Manhattan ContrarianCOMMENTSKevin kilty A day agoThere is a fairly extensive scientific literature going back two decades on the effectiveness of masks, and the bulk of it appears to fail to find any effectiveness that couldn't be ascribed to "chance". Some of this evidence is randomized clinical trials, and some of it actually involves making measurements of particle distributions passing through masks. Home-made cloth masks have zero effectiveness. Respirators made to standards, like N95 and N98, have the effectiveness they were designed for and no more. People who insist on the necessity of mask mandates don't and won't read this literature. An observation about blowing out candles does not qualify as evidence.I have tried to point out to anyone who will listen that the way people have promoted the effectiveness of masks is problematic. It is well known and has been for half a century that people miscalculate, under-estimate especially, risks when they think they are in control of a situation. The endless promotion of masks as the solution for the COVID-19 epidemic may have caused people to become nonchalant about risks. People who under-estimate risks the worst are often young people. It is a situation that could explain why a rise in cases often appears to follow a mask mandate.”Horowitz: Comprehensive analysis of 50 states shows greater spread with mask mandates”Hard to see science that shows masks work when Denmark hit all indoor spaces with mask mandate that failed to arrest the spread?Friends of Science@FriendsOScience“COVID is real, but perhaps the problem is health care and the lack of beds. In 2018 Canadian's had put improved health care at the TOP of their list of priorities, NOT #climatechange youtu.be/DF04nxUbV54 Think of the $$ in subsidies to BIG GREEN. Could have added beds+staff.