Too few nurses to hire: hospitals are maxed out and staffing ratios will harm access to care

Mandated staffing ratios may not solve the complex issues facing hospitals and nurses.  Echo editorial opinion:

As the Bangor Daily News Editorial Board talked to nurses who support legislation to mandate staffing ratios and a representative of hospitals, which oppose the bill, a system in crisis was agreed on.

As people have become sicker, and mental health and substance use disorder needs go untreated, hospitals — particularly emergency rooms — have become increasingly dangerous and unpleasant places to work.

Both groups agree that this crisis needs immediate attention. They also agree more nurses are needed in hospitals and other health care settings. They disagree on how best to accomplish this.

The Maine State Nurses Association supports LD 1639, which would mandate specific ratios of registered nurses to patients. For example, one-on-one care would be required in operating rooms and intensive care units. Nurses could care for four patients receiving pre-surgical and rehabilitative care.

The bill is sponsored by Senator Stacy Brenner, D-Scarborough, who worked as a nurse-midwife.

“The bill … accomplishes two primary goals: increasing patient safety and encouraging nurse retention,” she said in a press release.

“The care and touch of a knowledgeable and dedicated nurse in those times when you are feeling most vulnerable greatly increases patient satisfaction, dignity, and the overall perception of their hospital experience,” she added. “This is a bill for everyone. But, most especially, this is a bill for bedside nurses.”

Brenner (who was a midwife) and other nurses spoke about their increasing frustration with working long, and sometimes unpredictable hours, while worrying that their patients were not getting the care they need and deserve.

This stress is understandably wearing on nurses, prompting many to leave the profession.

This situation is unsustainable, Cokie Giles, who has worked as a nurse at Northern Light Eastern Maine Medical Center in Bangor for 34 years, told us. There is not a nurse shortage, Giles, who is the president of the Maine State Nurses Association, told us. Rather, there is a shortage of nurses willing to work under current conditions.

And here is the crux of the problem. While studies have found that patients have better health outcomes when nurses care for fewer patients, there are, unfortunately, economic and human resource realities to consider.

There are already 1,500 nursing vacancies, according to Jeff Austin of the Maine Hospital Association. The association estimates that another 1,000 nurses would be needed to meet the standards in Brenner’s bill.

We are skeptical that requiring fewer patients per nurse will solve the many reasons driving people to leave the nursing profession or choose not to work in hospitals. Many nurses now work as traveling nurses, which typically pays more than being on staff at a hospital, or work in medical offices that don’t have the stress and chaos of a hospital, which must take any patients that show up at their door.

At a time when Maine already has a nursing shortage, we are concerned this bill would make the situation worse without addressing the underlying causes of worsening conditions in hospitals in Maine, and across the country. This could mean that hospitals would have to close units and deny care if they couldn’t hire enough nurses to meet the mandates in LD 1639. This could be one reason that no state, except California, has adopted broad nurse staffing ratios like these. Massachusetts has mandated nurse staffing ratios for intensive care units.

Without more mental health beds, for example, too many patients are spending time — often weeks or even months — in hospital emergency rooms. This is horrible for the patients and the medical care caring for them. Solving problems like this requires a much larger commitment — namely funding — from the state to grow the availability of mental health services.

This is just one of the significant and complex issues facing hospitals. That is not to say that hospitals, and other medical practices, should not invest more in improving working conditions. They (hospitals) cannot, however, hire more workers if those workers don’t exist.

Republican party needs a reset - Echo opinion

Opinion echo published in the Bangor Daily News.

Kurt Bardella is a senior adviser to the Lincoln Project. He is a former aide to California Republican Reps. Darrell Issa and Brian Bilbray and former Maine Sen. Olympia Snowe.

Kurt Bardella

https://bangordailynews.com/2021/01/01/opinion/contributors/its-never-too-late-for-republicans-to-leave-the-party/

There was a time when being a Democrat or a Republican was defined by your views about health care, abortion, gun control, taxes, education, foreign policy, etc.

Those days are over.

It was something to hear Sen. Mitt Romney, Republican of Utah and the party’s standard-bearer in 2012, tell CNN’s Jake Tapper on Dec. 20, “I represent a very small slice of the Republican Party today.” An obvious, but candid, acknowledgement.

As he explained, the party he knew as a young man — and even just eight years ago — is gone.

“We were a party concerned about balancing the budget. We believed in trade with other nations. We were happy to play a leadership role on the world stage, because we felt that made us safer and more prosperous. And we believed that character was essential in the leaders that we chose. We have strayed from that. I don’t see us returning to that for a long time.”

Yet, when asked whether he thinks about leaving the GOP, Romney — like other Republicans who say they are repulsed by Donald Trump’s takeover — declined. He said he would be more effective battling inside the party. But I venture that’s only part of the rationale.

As someone who left the Republican Party to become a Democrat for similar reasons, people often ask me how I could have stayed in the GOP after Trump won.

The truth is, changing your political identity is one of the hardest things you’ll ever do. For a person in politics — for the thousands of elected officials, staffers, local party officials, the entire political class really — it means unplugging from everyone you know and the foundation of your professional and social life. Imagine spending years of your life building relationships with like-minded people, and then one day, deciding to start over.

When you work in politics, your party is your team and your career. No one goes into politics without loving that life. If anyone thinks it is easy to casually discard all that because it is “the right thing to do,” you honestly have no idea what doing so really means.

That’s why, when Trump took office, many in Republican circles clung to the belief that he could be steered or managed. That, despite the inflammatory words, and actions that littered the campaign, the adults in the room would be able to contain Trump and preserve the political goals of the Republican Party.

I went through that very cycle when I made the decision in 2017, to leave the GOP. In doing so, I had to accept that I might not work in professional politics ever again. Back then, there was no Lincoln Project and nowhere for a former Republican-turned-Democrat to land.

Three years later, the situation in our country is even more dire. Republican leaders refuse to stand up to Trump even now, and by staying silent, are actively aiding and abetting his deranged plot to steal the election and undermine the will of the people.

I appreciate where Romney is coming from, but there comes a point where an institution is so thoroughly broken it must be rebuilt someplace else. The party’s true platform has become a toxic combination of authoritarianism and white nationalism. Rebuilding the party will require dismantling it. And helping in that cause doesn’t mean becoming an independent or agitating for a third party.

In the American two-party system, it means joining the other side — the Democrats. Steve Schmidt, Lincoln Project co-founder and John McCain’s campaign manager in 2008, explained why in a recent interview. “At the end of the day, there’s now one pro-democracy political party in the United States of America and that’s the Democratic Party,” he said. “And I am a member of that party because of that. I’m a single-issue voter. I believe in American democracy.”

At the start of the Trump presidency, anti-Trumpers who identified as Republicans stayed with the team hoping that their policy positions would still form the basis of a Republican agenda. That experiment is over.

If you were a Republican because you believed in fiscal restraint, under Trump the debt and deficit have exploded. If you were a Republican because you believed the GOP was stronger on national and homeland security, just look at what Trump said recently in cynically downplaying Russia’s cyberattack against our country. If you are a Republican because you believe in law and order, examine the records of the corrupt people Trump just gave pardons and commutations to. If you are a Republican because you are pro-life, there are more than 340,000 Americans dead from COVID-19 to call into question the GOP’s commitment to the sanctity of life.

Whatever issue has kept you aligned with the Republican Party, it’s time to accept that none of those issues supersedes the welfare of our democracy. When your party takes leave of its senses and takes its lead from the delusional rantings of a conspiracy theorist, it’s time to switch teams.

America must move beyond Donald Trump's mismanaged failed administration!

"Sore-loserism!" #DonaldTrump

An echo opinion by Amy Fried published in the Bangor Daily News, a Maine newspaper. 

Donald Trump has generated one shock after another. First as a candidate, then as president, Trump tweeted nasty insults, promulgated conspiracy theories, mishandled the pandemic and the attendant recession, and empowered corrupt, incompetent cronies.

Dealing with these incessant hits has been like responding to a child who eats way too much sugar. Every additional morsel unleashes a whirling dervish, acting with abandon and no concern for others.

The latest jolt to our body politic is the news that Trump discussed unconstitutional means of staying in office after losing the presidential election — an imposition of martial law, seizing vote counting machines and rerunning the election. If that happened, the U.S. would be an autocracy, not a democratic republic.

A senior administration official quoted by Axios reporter Jonathan Swan warned, “it’s impossible not to start getting anxious about how this ends” when Trump is “retweeting threats of putting politicians in jail, and spends his time talking to conspiracy nuts who openly say declaring martial law is no big deal.”

In a never before needed statement, top Army leaders made it clear they won’t participate in a coup, saying, “There is no role for the U.S. military in determining the outcome of an American election.”

Yet, this authoritarian sore-loserism yielded very little response from politicians.

Most likely they think Trump won’t try to use the military to stop Joe Biden from taking office. And some Republicans are still afraid of crossing Trump, because they don’t want to turn off Trump’s base.

(Maine Writer- Is Republican Senator Collins among these "flakes"?)

Deep tiredness is also part of the nonresponse to Trump’s latest flirtation with dictatorship. As political scientist Daniel Drenzer puts it, Trump has been the “toddler in-chief.” Because undisciplined toddlers require close attention and intervention, they are just very exhausting to be around.

As American politics recovers from Trump’s poisonous sugar high politics, three dynamics will drive it.

First, President-elect Biden brings a calmness to replace our frenetic recent reality. Biden doesn’t do name-calling and there are no tantrums. He’s not irritable, easily distracted or full of braggadocio.

It’s been comforting, really, to watch his events introducing Cabinet nominees. What we see is a grownup who works with other grownups, all of whom care about communicating and governing with quiet competence.

Take the event put together by the Biden transition last week to introduce his Climate Team. Between statements by Biden, Vice President-elect Kamala Harris and individuals picked to serve in the incoming administration, listeners learned two sorts of things. One was the personal and professional lives of those selected.

But besides this inspiring, illuminating information, you could hear the administration’s strategic approach. For Biden and Harris, tackling climate change wasn’t a stand-alone concern. Rather, it was tied to health problems caused by pollution and disparities in which communities suffered from environmental damage, repairing frayed international relations, and creating millions of well-paying jobs.

Second, particularly if Mitch McConnell continues to control the U.S. Senate, passing Biden’s legislation will be exceedingly difficult. In the latest COVID bill, Republicans prioritized aid to corporations as Democrats focused on helping low-income and middle-class Americans.

Biden knows that. Barack Obama recalled in his memoir that “Biden told him of how McConnell had blocked one of his bills. When Biden tried to explain the bill’s merits, McConnell responded, ‘You must be under the mistaken impression that I care.’”

But Biden’s experience, knowledge and team will help him get some things done in Congress and through executive action. What we’ll see mostly is a slow, grinding policy process with some notable successes.

Third, Trump will lurk as a vocal observer and meddler. He’s tried to undermine the transition. If he again runs for president, he’ll freeze the race. Although his claims of non-existent voting fraud have been dismissed by the courts, most Republicans are believers.

But for most — who never approved of Trump’s job performance, didn’t back him in 2016 or 2020, and think Biden won this year’s election — Trump’s statements as a former president will just become part of the background noise.

And so Americans, recovering from the Trump era, will move on.

Senator Susan Collins nonsensical comments - echo blog

Bangor Daily News blog echo posted by University of Maine History Professor Howard Segal:

Senator Susan Collins:

She must think that most Maine voters are idiots

Is Collins serious in thinking that her long and growing list of ridiculous excuses for supporting President Trump AND his Judicial nominees fools most of us? True, the core members of the Collins cult would jump off a mountain if so ordered. But even their blind faith in her support for the GOP may have its limits.

If, to be sure, the late great social critic H.L. Mencken said that no one ever lost money underestimating the taste of the American people, what might he have said about Collins’ nonsensical comments and speeches.

I love when Collins allegedly needs time to contemplate votes she had decided upon weeks ago.

“Our Senator” will not be able to walk back her right-wing politics for ever.

Impeachment witnesses were brave and credible - out did cowardly colleagues who will not yet submit "under oath"

"...everybody was in the loop, including the vice-president (Mike Pence), the secretary of state (Mike Pompeo) and White House acting Chief of Staff (Mick Mulvaney)..."- Fiona Hill.

The impeachment witnesses are the silver lining to this embarrassing chapter in our history

Echo opinion by Kathleen Parker published in the Bangor Daily News, a Maine newspaper.

Former White House national security aide Fiona Hill testified under oath before the House Intelligence Committee on Capitol Hill in Washington during a public impeachment hearing of Donald Trump's illegal efforts to tie U.S. aid for Ukraine to investigations of his political opponents.

After fidgeting through five days of public hearings, a dozen witnesses and countless political pontificators, Americans should be gratified by the quality of the people who testified and who actually do the nation’s work abroad.

If there was a silver lining to an otherwise embarrassing chapter in our history, it was that we were able to meet and hear from those whose names aren’t well known except to their colleagues. To listen and observe was to have one’s faith restored in America’s image despite the withering damage suffered these past few years.

One after another, the men and women who testified, subjecting themselves to the sometimes-scurrilous scrutiny of political profilers, maintained their focus and their cool. It was grating to hear the screech of Rep. Jim Jordan, R-Ohio, whose raised voice surely signaled a stretch-and-restroom break for many viewers. While we’re on the subject, can’t the man put on a blazer? Jordan appeared without one, putting in mind a teenager who refuses to play by his parents’ rules.

May I remind him and others that dress codes are intended to show respect for the occasion and for others in attendance. Surely, our congressional leaders owe their constituents — and, in this case, the process — the small personal sacrifice of dressing appropriately. To do otherwise is to telegraph to the world that you think you’re more important than everyone else. Jordan also proved that age and maturity can be mutually exclusive.

There, I got that off my chest. (Parents may clip for personal use.)

Quite apart from the question of whether Trump should be impeached, viewers of the hearings were privy to history and were beneficiaries of a primer on current events. Often lost in the drama of the impeachment proceedings is the profound importance of Ukraine as a buffer to a resurgent Russian empire. 

Trump’s withholding of $400 million in military funding from Ukraine during its war with Russia — pending assurances that Ukrainian President Volodymyr Zelensky would at least say he’d investigate the Biden’s involvement with the gas company Burisma — put Ukrainian lives at risk and signaled to Russia that U.S. support of Ukraine was credibly iffy.

One of the pivotal questions during the hearings was whether America’s diplomatic corps understood that “Burisma” was actually code for the “Bidens,” meaning political rival Joe Biden and his son Hunter, who was employed by Burisma. Only two witnesses claimed not to have known about the connection. One was Kurt Volker, a former envoy to Ukraine, who later said he should have caught on sooner. The other was U.S. Ambassador to the European Union Gordon Sondland, whose claim was deemed “not credible” by witness Fiona Hill, the National Security Council’s former senior director for Europe and Russia, and a standout in the lineup of witnesses.

At several junctures, Hill schooled House Intelligence Committee members about the significance of Ukraine and the perils of advancing the false claim that Ukraine and not Russia had interfered with the 2016 election. “This is a fictional narrative that has been perpetrated and propagated by the Russian security services themselves,” she said. Critical of partisan rancor, she beseeched members to “not promote politically driven falsehoods that so clearly advance Russian interests.”

As for the inferred quid pro quo between Trump and Zelensky, Hill confirmed Sondland’s earlier testimony that “everybody was in the loop,” including the vice president, the secretary of state and the White House acting chief of staff.

While true that the administration under pressure did release the military-aid funds, without Zelensky’s public announcement of an investigation, which Trump had specifically requested, his intentions alone created problems for those serving in Ukraine. In Hill’s words: “[Sondland] was being involved in a domestic political errand. And we were being involved in national security, foreign policy. And those two things had just diverged.”

Whether Donald Trump is impeached remains to be seen. But the shame of his highly irregular behavior in seeking political favors from a foreign entity is softened somewhat by the pride one can feel in our diplomats, experts and fact witnesses to whom we are beholden for their good grace.

Kathleen Parker is a columnist for The Washington Post. 

Hill’s testimony jibed with earlier testimony by acting Ukraine Ambassador William Taylor that there was a regular policy executed by the diplomatic corps and a “highly irregular” policy run by Rudy “Hand Grenade” Giuliani, whose legacy as former New York City mayor, we should note, has definitively expired.

"....and our Flag was still there....." Freeport Maine Flag Ladies

An echo blog published in the Bangor Daily News, written by blogger Michael Cianchette

 Maine’s own “Freeport Flag Ladies” have decided to retire.

The end of an era is upon us.

For 18 years, the Freeport (Maine) Flag Ladies spent at least one day, every week, standing along Route 1, through Freeport. 

They weren’t pushing a political message or advocating for partisan policy positions. Instead, they simply wanted to demonstrate love for their country and demonstrate their patriotism.

There is something noble in its simplicity. The American flag hoisted proudly, in rain or shine. A message to the world that, no matter what trials we undergo, we shall remain. After the twin towers fell on September 11, 2001, Francis Scott Key’s words rang anew: the flag was still there.  (The Star Spangled Banner)

JoAnn Miller, Elaine Greene and Carmen Footer

The flag has a particular resonance in the world today. For those of us here, it sometimes feels like things are falling apart. The political warfare in Washington DC, between partisan camps, fills headlines, online and over the air. The actual warfare between white supremacists and “Antifa” (political protests) spills violence into our streets.

But the flag — and the idea of America — means more. For weeks on end, Hong Kong has been gripped in the throes of civil unrest. Protestors have struck back against an encroaching Chinese imperium. In the midst of it all, the Hongkongers waved the American flag and sang the “Star-Spangled Banner.” The flag — and the ideals for which it stands — was still there.

Which brings us back to the Freeport Flag Ladies. The power of symbolism was readily apparent. It served as a rallying cause for disparate groups. Every political leader wanted to stand with them, outside of the iconic L.L. Bean. 

What they did was the right thing to do.

Since the three ladies started standing with their flags shortly after Sept. 11, 2001, the United States has entered two “big” wars in Afghanistan and Iraq. We’ve also been brought into “smaller” wars in Libya and Syria, among others. Men and women with the American flag proudly displayed on their right arm, stars forward to reflect an advance, went forward to do their jobs on behalf of their nation. And, in most cases, our flag is still there.

Its worth remembering as America considers its future on the world stage. On Nov. 3, 2020, ballots will be cast for president by people who were not yet born on Sept. 11, 2001. The twin towers are a memory they received from a world which existed before them. And 34-year-old Sgt. First Class Elis A. Barreto Ortiz lost his life in Afghanistan on Sept. 5, in an effort that has literally been in existence for the entirety of their lives.

However, while Hongkongers wave the American flag in hopes that American values may be maintained, the Afghan people had the opposite experience. The Taliban government in Kabul, seizing power after the Soviet withdrawal in the 1980s, placed most of the country under a totalitarian regime. When American forces arrived, the Afghan people had a new chance at life.

Since the Freeport Flag Ladies began their watch, Afghanistan has joined the modern world — 84% of Afghans support women’s education, while 61% are satisfied with democratic freedoms. The biggest problems facing young Afghans are a lack of jobs and schools, not a multitude of beheadings.

That all happened because the American flag — inextricably tied to Americans themselves — found its way to Afghanistan. There are plenty of political and policy conversations to have concerning our role in the world. How much blood and treasure should we invest abroad, versus deploying at home? It is a real question with no clear answer.

But, whatever answer we come up with, our American flag will follow, both here and on foreign shores. So, even if the Freeport  (Maine) Flag Ladies will not be holding the Stars and Stripes aloft weekly, their efforts have inspired countless others. The flag will still fly in Freeport, and Hong Kong, and Afghanistan. And wherever it is, there our ideals will be.

Maine legislature must fix the mis-information about citizens veto election date

What a mess! 

Maine secretary of state gave people’s veto efforts bad guidance on election date- Bangor Daily News by Michael Shepherd. Following the publication of this article, the Bangor Daily News published an editorial to support the groups that are looking to overturn the Secretary of State's wrong advice.  

AUGUSTA, Maine — Leaders of three efforts to overturn major laws passed by Maine’s Democratic-led Legislature said they’re considering “all options” — including a referendum and lawsuits — after getting inconsistent guidance on the timing of a people’s veto election.

The office of Maine Secretary of State Matt Dunlap, a Democrat, told the Bangor Daily News last month, if the recall efforts made the ballot, the election would be in March 2020, because of a constitutional provision slating people’s veto efforts for the next statewide election.

Proponents of the effort said Dunlap’s office told them at the outset of their campaigns, that the election would be held in June. 

There’s a major difference between the two, since March is when Democrats will hold Maine’s new presidential primary. With Donald Trump facing no serious Republican primary threat, the electorate in March would be dominated by Democrats.

They would be unlikely to back the people’s veto efforts, which would mostly rely on conservatives who favor repealing laws passed in 2019, to allow doctors to prescribe (suicide) life-ending medication to terminally ill patients, allow abortions to be funded with state Medicaid money and end nonmedical exemptions to school vaccine requirements (and others).

Backers of those campaigns met with Dunlap on Thursday, where he took responsibility for the unclear guidance given by his office. He said later in the day that his office did not account for the new primary law — which passed at the end of the legislative session in June — when giving the guidance days later. His office’s stance is that the election will be in March.

People's veto process in Maine hits an unforeseen glitch: Calls for March 2020 correction

This election ruling, about a date based on Maine's newly enacted primary law, was not properly communicated to civic leaders. 

Groups are already working on people's vetoes- especially to recall the laws passed about Medicaid funded abortion (L.D. 820) and physician assisted suicide (LD 1313).  Therefore, there should be legislative action to solve the glitch about the date for the recalls election, at least for the upcoming primary in March 2020. 

Meanwhile, the Secretary of State must promulgate policies to put in place for future people's vetoes processes. This editorial board echo position by the Bangor Daily News explains the problem and the proposed solution: 

Maine's legislature must fix this problem for March 2020, because, otherwise, the electorate will be overwhelmingly Democratic in response to the presidential primary and thereby suppress a balanced response to the recalls of several Republican supported initiatives.  

BANGOR, Maine- The Maine Secretary of State’s Office made a significant mistake when it gave inaccurate guidance to groups involved with current people’s veto efforts.

Secretary of State Matt Dunlap, a Democrat, has rightly taken responsibility for this situation — a situation that is somewhat understandable given the complexity of the matter at hand, but nevertheless unacceptable.

Organizers behind several of these separate people’s veto efforts, which in total aim to overturn 12 of the new laws passed by the Democratic-controlled Legislature, were incorrectly told by Dunlap’s office that if they received enough signatures for their petitions by the mid-September deadline, they would likely have their veto efforts on the ballot next June.

The State Constitution sets ballot-qualifying people’s vetoes for the next statewide election. People’s veto organizers would have needed to submit their signatures by early August in order to get their veto on the ballot this November. Dunlap says he and his staff failed to initially realize that Maine’s new presidential primary system, created this legislative session by a billsubmitted on behalf of the Secretary of State’s office, means that the next statewide election after November is actually in March, not June.

“Honest to God, it just never occurred to us,” Dunlap told the Bangor Daily News, about the impact the presidential primaries law is now having on people’s veto efforts, noting that the presidential primary discussion had focused on the mechanics and timing of switching from caucuses to primaries.

“I felt really, really bad for them,” he said about current people’s veto organizers and the realization that they received inaccurate guidance, describing them as now being “caught in a headlock here”, as they face the prospect of trying to pass Republican-leaning veto efforts during a primary election that is expected to be dominated by Democratic participation.

Carroll Conley, executive director of the Christian Civic League of Maine, said in an interview with the BDN how the inaccurate guidance factored in to his group’s calculus of whether to try to rush and collect signatures to make it on the November ballot, or take the extra time and instead plan on a June election. With the wrong information they received, the League and other groups didn’t have a chance to evaluate the choice between November and March.

“We are not crying conspiracy here,” Conley said of the incorrect guidance, while acknowledging the difficult situation it presents. “I think it totally blindsided everybody.”

Conley emphasized that he was speaking only on behalf of the Christian Civic League, which is just one of several groups working on veto efforts. He said his group still plans to keep collecting signatures, realizes that a March election is likely should it collect enough and hopes there can be some sort of remedy to the unexpected timing issue.

This is an undoubtedly unfair, seemingly unprecedented complication for the organizers. According to the Secretary of State’s office, Maine did not have a people’s veto occur during the state’s brief previous experience with presidential primaries in 1996 and 2000.

There is a very good argument to be made that citizen’s initiatives and people’s vetoes should appear on the ballot at consistent, expected times when more people are likely to participate regardless of party affiliation.

That does not mean, however, that this timing mistake amounts to voter disenfranchisement, as some Maine Republicans have tried to suggest. People may be less likely to participate in this March election, but there is nothing stopping or impeding them from doing so. That is not disenfranchisement.

As an editorial board, we argued in favor of several of the new laws — including “ death with dignity,” vaccination and abortion access laws — that people are working to overturn with these vetoes. We almost surely will argue against some of the vetoes should they make it on the ballot. But those policy disagreements come later. This moment is about ensuring a fair and consistent process.

The important thing now is to move toward a solution to resolve this problem of election timing, which both Dunlap and a Republican legislator called an “unintended consequence” of the new presidential primary law. Another complication is that one of the current veto efforts seeks to overturn this new law.

In the meantime, Rep. Patrick Corey, R-Windham, is working on legislation with the aim of changing the presidential primary law to remove the word “election” and specify that people’s vetoes and citizen’s initiatives won’t be included in those primaries.

Dunlap said his office’s impression is that such a move may require a state constitutional change, but Corey sees it differently.

“We created the problem with statute,” Corey told the BDN. “I think we should be able to fix it with statute.”

Corey seems appropriately focused on the “process concern” here and not the politics.

“What we owe the people of Maine here is a conversation about getting this right — whatever that means,” Dunlap told the BDN.

The right thing for all involved here is to wade through the admittedly complicated procedural and constitutional layers and try to find a way to address this unintended consequence — not only in fairness to the existing people’s veto efforts and the people working on them, but for the integrity of the process moving forward.

Donald Trump policies create more crises than they solve because no strategy exists

An echo blog published in the Bangor Daily News by Gordon L. Weil, a former local, state, national and international organization official. He is an author and newspaper columnist.

TRUMP- “Whack-a-mole” is an arcade game that’s an exercise in futility. It has come to mean that each time you try to solve a problem, another problem pops up.

In the original game, players would hit the mole on the head, forcing it back into its hole. Another would pop up, and players had to move fast to hit each new one. 

Satisfaction from whacking each mole did not last long.

So, that's like much of American policy under Donald Trump. His strategy is like playing Whack-a-mole. In trying to fulfill his campaign promises, each problem that Trump attacks just leads to creating another.

Take China. It pursues unfair trade policies and has a trade surplus with the U.S. It also steals American trade secrets and forces U.S. companies to turn them over, if they want to do business in the huge Chinese market.

Trump whacked China by raising tariffs on its exports, a move reducing trade by making their goods more expensive. He believes that will bring them to the bargaining table, where the U.S. can win concessions.

But higher tariffs raise prices for American consumers. U.S. agriculture loses markets in China when it retaliates by increasing its own tariffs and buys elsewhere. The trade deficit with China has grown a little worse, according to official statistics.

More moles. Quit the Trans Pacific Partnership and lose allies opposing China and farm exports to Japan. Meet with the North Korean leader without result, but boost his international standing. Force a North American trade deal, creating hostility with neighbors.

Taxes are too high, stifling economic development, Trump says. They should be cut, notably for the middle class and for business, which will invest the money with the profits yielding offsetting tax revenues. Smack that mole.

In 2017, the GOP lowered taxes on the biggest taxpayers, also supposedly the biggest investors. It also allowed corporations to bring foreign profits home and cut the corporate tax rate.

But the tax bill’s economic effect faded by 2019. Corporations used added funds to buy back their stock and increase executive pay, with only a portion going into new productive capacity. Federal debt grew faster than the promised new tax revenues. That’s the new mole.


Or immigration, Trump’s signature issue. He warned that Mexican gangsters and rapists were streaming into the U.S. Building a wall, paid for by Mexico, would end the problem. Meanwhile, separating immigrant families is stepped up, supposedly to serve as a deterrent. (Trumpzi report: He has said, at least 20 times, that Mexico would pay for the stupid immigration wall- "not!")

But keeping his promise depended on Congress and Mexico, and neither agreed with him. Immigrants arrived in even higher numbers. They were not Mexicans, but mostly from Central America and Africa. Instead of U.S. aid to slow the flow at the source, it was cut. Americans were shocked by immigrant family separations.

Undeterred, Trump promised to sweep up millions of undocumented immigrants and deport them. But his immigration agencies were caught by surprise and were unready for the task. The president backed off, saying he wouldn’t carry out the threat if the Democrats agreed to his demands to change the immigration laws.

The mole: Iran. The nuclear deal with Iran was unsatisfactory, because 15 years later Iran could choose to resume its production of nuclear fuel. Also, the deal did not halt Iran’s aggressive moves in the Middle East.

The U.S. withdrew from the deal and has put strong economic pressure on European participants to force them to stop buying Iranian oil. No direct talks with Iran.

Iran announced that, if the U.S. stops its oil exports, it will restart nuclear fuel development that would have been forestalled under the deal. The situation became more tense than it was under the now-rejected agreement, as both sides rattle their sabers.

When Iran shot down an American drone, which the U.S. says was over international waters, Trump readied a retaliatory strike, but then backed off. He said the U.S. did not want to cause 150 deaths. Is it possible the U.S. was not absolutely sure of the drone’s location?

Trump has had some big successes. He has set a new record in sustaining President Obama’s economic recovery. He has induced European countries to increase NATO-related spending. He now has China’s attention.

But he usually announces immediate solutions – Whack-a-mole – instead of traditionally less dramatic, incremental measures, creating new problems.

Will the oncoming campaign and what he has learned as president lead Trump to cut back on playing the game?

In his recent immigration and Iran reversals, Trump may have begun to recognize that his sudden policy announcements raise new issues and don’t finally settle matters.

Maine Writer post script- and when Trumpzi's policies fail, as all of them have done, the creature will create a P.T. Barnam made for TV reality show, for the purpose of deflecting the headlines away from real news....and the media gives him the spotlight! Ugh! There is no strategy in the failed Trump administration because an idiot mole is running the government.

To choose to die is often determined by people who have a vested interest in the "choice"

Before people leap to the wrong minded notion that death is a choice, please read "The Death Treatment", an article published in the June 15, 2015, The New Yorker.

In Belgium, the law allows euthanasia for patients who suffer from severe and incurable distress, including psychological disorders. Photograph Courtesy Tom Mortier

In Oregon, it is reported that people who are living with diabetes can claim to have a terminal illness.  Of course, with the horribly inflated price of insulin, priced by greedy pharmaceutical companies, the likelihood of dying prematurely with diabetes is growing, due to the cost of receiving care.

An echo opinion published in the Bangor Daily News by Maine native, Mike Reynolds:

BANGOR DAILY NEWS- In what seems like a lifetime ago, I began my activism against assisted suicide in a small dorm on the University of Maine campus in Orono, never imagining that I’d still be arguing the same points about such a flawed law that was enacted in Oregon in 1997. 

That year I went to Washington, D.C., to protest outside the Supreme Court (on a day that was bitter cold by even Maine standards) as they heard the Vacco v. Quill case, which challenged the constitutionality of New York state’s ban on assisted suicide.

A year later I testified in front of the Maine Legislature for the first time against assisted suicide. By then, it had been defeated a handful of times. It failed that year as well, and voters soundly defeated a referendum on the same legislation in 2000.

Maine people know that when you are looking at issues of life and death, you look to the experts in their fields. In testimony at a work session on this same proposal in 2017, the Maine Hospice Council estimated there was a large segment of Maine, roughly the size of Rhode Island, that has no access to hospice or other palliative or end-of-life services. Legal options such as advance care planning are already available to let others know your healthcare wishes.

A bill heard in the Legislature in 2015 revealed that Maine does not have the infrastructure to provide care for individuals who have certain forms of neuromuscular disabilities and require the use of a ventilator. The only options then were care provided out of state.

We have no business discussing assisted suicide when quality palliative care is not accessible across the state. With Maine finally expanding its state-funded healthcare to populations who have gone without it for years, there are far too many issues that make assisted suicide incompatible with Maine values.

Proponents of assisted suicide like to point to the myriad of “safeguards” in their laws, but the reality is once the prescription is picked up from the pharmacy, there is absolutely no oversight in the law to protect the ill person from someone else who wants to hurry their death along, be it an insurance carrier, an heir or a caregiver.

And this is not a “dignified” death, it’s taking 100 tablets and emptying their bitter contents one by one into the recommend “sweet liquid” to consume. According to yearly reports released by the State of Oregon Division of Health, it can take anywhere from several minutes to more than 72 hours to die in this manner. According to the 2018 report, eight people actually woke up after taking the “sweet drink” since the law was enacted.

This law vastly redefines “terminal,” so broadly that the word may lose any real meaning. In Oregon, diabetes has been reported as a qualifying “terminal illness.” Anyone who needs medicine to keep a chronic illness in check would qualify if, by stopping the medication, the individual would likely die in less than six months. For people who have cancer, chemotherapy has even been denied in Oregon by state-run health insurance, which offered assisted suicide instead.

The effects of this law are felt far beyond the confines of the sick and terminally ill. The Centers for Disease Control in 2017 stated that Oregon had a 35 percent higher rate of suicide than the national average; it was even higher in younger populations. We should all be concerned about what kind of message a government sponsored, medically administered program of assisted suicide sends to anyone facing difficult times.

This legislation is a last-ditch effort of Maine Death with Dignity, which was trying to put the legislation out to referendum this year, and whose vast majority of financial backing comes from out of state, namely the Death with Dignity National Center, located in Oregon. Please contact your legislator and ask them to oppose LD 1313.

Mike Reynolds is a Maine native and member of Not Dead Yet, a disability rights group opposed to assisted suicide. He lives in Lewiston.

Republican rebuke is a crack in Humpty Dumpty's border wall

Donald Trump's chaotic signature has vetoed the bill he wanted to waste billions of tax dollars on a border wall that he said Mexico was going to pay for!

An echo opinion published by the editorial board of the Bangor Daily News in Maine

Donald Trump lost his way by supporting an expensive and unnecessary board wall doing so just because "he could".  

Although the Republican rebuke of Trump's executive and selfish overreach may not override his stupid EKG style veto signature, the fact is, there is a crack in his political Humpty Dumpty veneer. 

Donald Trump lost his ability to support the unnecessary border wall. Like Humpty Dumpty, Trump the tRumpf, has had a great fall. Although he might scribble his way to a successful veto override, the fact is, his Republican Senators have put a crack in his political veneer.

A dozen Republican U.S. senators bucked Donald Trump by supporting a resolution to negate last month’s emergency declaration, setting up the president’s first veto. 

Trump plans to use the declaration to divert about $8 billion that Congress has already allocated to other purposes toward building more barriers on the southern U.S. border.

Those 12 senators who broke ranks from Trump — including Maine’s Susan Collins, the first Senate Republican to indicate she would support a resolution of disapproval — stood up for the separation of powers in the face of significant political pressure from their own party.

There are two problems with Trump’s emergency declaration. One, the administration has not demonstrated that the situation at the U.S.-Mexico border rises to the level of an emergency. 

Certainly, improvements in border security are warranted, but Trump has undermined his own position by bragging that construction of a border wall is well underway, and saying that he said I “didn’t need to do this, but I’d rather do it much faster” while announcing the declaration.

Second, and more important, Trump’s plan to reroute billions of dollars approved by Congress for other purposes raises glaring constitutional concerns. The U.S. Constitution gives Congress — not the president — the power to raise and spend federal funds.

This fundamental problem led Sen. Susan Collins to take the lead in introducing a bipartisan resolution to end the emergency. A House version passed with a bipartisan vote of 245-182 in February.

“Let me be clear: The question before us is not whether to support or oppose the wall, or to support or oppose the president. Rather, it is this: Do we want the executive branch — now or in the future — to hold a power that the Founders deliberately entrusted to Congress?” Senator Collins said on the Senate flooron Feb.28. 

"It has been said that Congress’s most precious power is the power in the purse — set out in plain language in … our Constitution.”

“The president’s emergency declaration is ill-advised precisely because it attempts to short-cut the process of checks and balances by usurping Congress’s authority,” she added. “This resolution blocks that overreach, and nothing more.”

As an example of that overreach, Collins cited work at the Portsmouth Naval Shipyard in Kittery that would stop if the president took money away from these projects to pay for border wall construction.

The rest of Maine’s congressional delegation — Sen. Angus King and Reps. Chellie Pingree and Jared Golden — similarly stood up for Congress’ constitutional authority by backing the resolution.

Despite securing enough support in both houses, the 59 votes for the resolution in the Senate is still not enough to override the veto Trump issued Friday. It is his first veto. That leaves the courts as the next step for debate over the emergency declaration.

It was, however, a fight worth having because Congress is long overdue in reasserting its status as a co-equal branch of government.

“Never before has a president asked for funding, Congress has not provided it, and the president then has used the National Emergencies Act of 1976 to spend the money anyway,” Republican Sen. Lamar Alexander of Tennessee explained after the vote, also noting that he generally supports the president on border security. 

“The problem with this is that after a Revolutionary War against a king, our nation’s founders gave to Congress the power to approve all spending so that the president would not have too much power. This check on the executive is a crucial source of our freedom.”

If nothing else, the president’s misguided and legally questionable border wall emergency declaration should be a call to action for constitutionalists in both parties to address the overly broad scope and use of the National Emergencies Act. But it could also be much more.

As said before by the Bangor Daily News editorial board, the preferable, if unlikely, way forward here is for Congress to fully reject Trump’s emergency declaration, scale back the extent that the presidency is empowered through the National Emergencies Act, and take another shot at more comprehensive immigration reform — including increased funding for barriers on the southern border, protections for immigrants already here and other needed updates to our immigration system.

When Donald Trump promised the coal industry a pipe dream. Illusion and lie.

COAL- the illusion of prosperity was a lie
The company that did everything right is failing- Cloud Peak Energy Inc. was supposed to be the smartest company in coal.
But with debt mounting, the industry model might be on the auction block in a demoralizing tale for an industry already short on hope.

‘Trump people’ (Trumpzis!) are the ultimate victims of the Donald Trump hoax

Donald Trump promised the coal miners a pipe dream. 

An opinion echo published in the Bangor Daily News by Dana Milbank, a columnist who write for The Washington Post

Last August, Donald Trump went to Charleston, West Virginia, for a “mission accomplished” (failed) moment.

He had already boasted to his Fox News (cult!) fanbase that “I’ve turned West Virginia around, because [of] what I’ve done environmentally with coal.” 

In Charleston, he said that “we are putting our great coal miners back to work” by ending what he had dubbed the Obama administration’s “war on coal” and that, under his leadership, West Virginia had “on a per capita basis one of the most successful GDP states in our union.”

Coal Peak Energy coal stocks have been tanking for years

Quarterly figures are volatile, but clearly, two years into the Trump presidency, both West Virginia and the coal industry remain in bad shape. Coal-plant closures nationwide reached a near-record in 2018, production was off sharply, and U.S. coal consumption hit a 40-year low. Jobs in coal have barely budged, from 51,000 at the end of 2016 to 52,700 today.

West Virginia’s poverty rate, meanwhile, rose to 19.1 percent, among the nation’s highest, in 2017, the most recent year of reported data. The state is being propped up by temporary jobs (often held by out-of-state workers) to construct pipelines for natural gas. And the national economy, though humming along, isn’t near the level of growth Trump promised his debt-expanding tax cuts would deliver.

Trump pulled out of the Paris climate agreement, led a rollback of environmental regulations such as the Obama administration’s Clean Power Plan, attacked renewable energy and sought bailouts for failing coal-fired power plants. He quickly claimed success. “Coal production up 7.8% past year,” he tweeted in October 2017.

The main threat to coal, however, wasn’t a regulatory “war” but market trends favoring natural gas and renewables. Inevitably, reality overtook Trump’s hype.

Last week, owners of one of the largest coal-fired power plants in the country said they would resume plans to shut the Arizona plant down after negotiations to save it had stalled. Days earlier, the Tennessee Valley Authority said it would shutter a Kentucky plant despite pleas from Trump.
U.S. utilities last year closed an estimated 14.3 gigawatts of coal-plant capacity, double the closures of the year before and nearly matching the record 14.8 gigawatts that were retired in 2015, according to S&P Global Market Intelligence.

West Virginia’s coal industry has been a bit luckier because demand for its metallurgical coal has been healthier, but signs suggest that demand is now cooling. The state’s unemployment rate remains among the nation’s highest.

The national economy, though performing far better overall than the coal industry and West Virginia, is also falling short of the hyped promises that Trump has made.

During the campaign, Trump said of annual economic growth: “We’re bringing it from 1 percent up to 4 percent. … I think you can go to 5 percent or 6 percent.” In December 2017, he saw “no reason why we don’t go to 4 percent, 5 percent and even 6 percent.” 

White House (fake!) forecasters assumed a decade of 3 percent annual growth, which would require much higher growth in boom years to offset downturns.

But last week, the government reported 2018 growth of 2.9 percent — despite the maximum stimulative benefit of Trump’s $1.5 trillion tax cut and a boost from massive deficit spending in an already expanding economy.

Certainly, 2.9 percent growth is good — equaling the best year of Barack Obama’s presidency, 2015. And manufacturing job growth has accelerated under Trump. But this isn’t close to the “4 percent, 5 percent and even 6 percent” Trump predicted, and forecasters see growth slowing this year and in 2020.

As Bloomberg News reported, a just-published study by economists from the Federal Reserve Bank of New York and elsewhere found that Trump’s trade policies were costing U.S. companies and consumers $3 billion a month in tax costs and businesses an additional $1.4 billion in other losses.

Another study, by a group that includes the World Bank’s chief economist, found that “workers in very Republican counties bore the brunt of the costs of the trade war.”

They, like the coal miners, the steelworkers and West Virginians — those whom Trump’s trade adviser recently dubbed “Trump people” — are the ultimate victims of Trump’s economic hoax.

Dana Milbank is a columnist for The Washington Post

Health Care cost shifting in another plateau - put physician costs on another possible out of network bill!

Hospital visits for some Maine residents could become more complicated, and costly

MaineWriter- In my opinion, this in depth article points out how hospital cost shifting has now reached a new plateau. Patients will receive surprise bills from TeamHealth. 

By Charles Eichacker Bangor Daily News

Visits to the hospital are never fun, and they’re rarely straightforward.

But for some residents of eastern and central Maine who have a medical emergency — a broken leg, an allergic reaction, chest pain — seeking help is about to get more complicated.

It could cost more, too.
Starting early this year, many doctors who staff hospitals in Blue Hill, Ellsworth, Pittsfield and Waterville will no longer work for the hospitals themselves or its parent organization, Northern Light Health. Instead, they’ll work for a company based more than 1,000 miles away. TeamHealth, a physician staffing firm headquartered in Knoxville, Tennessee, has signed a contract with Northern Light to employ the emergency medicine and hospitalist doctors in those four hospitals.

That means patients who see those doctors would get a separate bill from TeamHealth, in addition to any others from Northern Light.

It also means patients who have confirmed that their local hospital accepts their insurance could be in for a shock: It’s not a given that TeamHealth will accept that insurance, too. If it doesn’t, patients could be stuck with a hefty bill.

Northern Light administrators say the new partnership will help the system — formerly called Eastern Maine Healthcare Systems — deliver stronger, more efficient hospital care. It comes as the organization has struggled to fill open positions at those small, regional health centers in recent years.

Yet at a time when Americans have grown increasingly wary of the steep costs and mysterious origins of medical bills, TeamHealth’s arrival could also put new, upward pressure on the price Mainers pay for a trip to the hospital.

In particular, if TeamHealth refuses to accept the prices offered by Maine patients’ health insurers, patients could be exposed to costly out-of-network bills.
A recent study from Yale University found that when TeamHealth and one of its competitors entered hospital emergency rooms between 2011 and 2015, a greater share of patients with health insurance accepted by the hospital ended up seeing physicians who were outside their insurance network.

The resulting bill from an unknown, out-of-network contractor could be more than double what the insurer was willing to pay, according to the Yale research. When that happens, patients may then be asked to cover the difference, and the so-called “surprise” or “balance” bill can reach hundreds or thousands of dollars.

Alternatively, if insurers agree to the steeper bill, they can pass that price on to patients through higher premiums.

While Northern Light administrators say that any insurance patients have used in the past should still work under the new partnership, a TeamHealth spokeswoman said the company may send out-of-network bills to Maine patients.

In 2014, about 20 percent of inpatient admissions and 14 percent of outpatient visits to ERs in the U.S. led to out-of-network bills, according to a report by the Federal Trade Commission. 

A recent poll by the Kaiser Family Foundation found four in 10 Americans said they’d received a surprisingly large invoice for medical care in the last year.

Members of Congress, meanwhile, have started considering solutions to the problem. In Maine, a law that took effect at the start of 2018 aims to protect patients from surprise, out-of-network bills. TeamHealth’s entrance into the four Northern Light hospitals could test the strength of the new law.

Some members of the health care industry have said out-of-network billing isn’t common in Maine, but it has been reported here. 

Ann Woloson, executive director of the Augusta-based advocacy group Consumers for Affordable Health Care, has heard from patients who thought a hospital and surgeon would take their insurance, for example, then were billed by an out-of-network anesthesiologist.

Besides the questions about TeamHealth’s billing, it’s still unclear what specific changes are coming to the staffing of the four hospitals under the for-profit contractor: 

1.  Northern Light Blue Hill Hospital

2.  Northern Light Maine Coast Hospital in Ellsworth

3.  Northern Light Sebasticook Valley Hospital in Pittsfield 

4.  Northern Light Inland Hospital in Waterville

The TeamHealth spokeswoman and Northern Light administrators didn’t respond to specific questions about how many clinicians will work at those hospitals going forward, but both emphasized their focus on improving quality outcomes. 

Nevertheless, one doctor, who said he was offered a contract to work at one of those hospitals under TeamHealth, questioned whether there will be adequate emergency room staffing.

Woloson knows little about TeamHealth and hopes the new arrangement will allow quality physicians to keep working in rural places like Blue Hill and Pittsfield, where it can be hard to attract well-trained professionals. Yet she questioned how Maine patients will be asked to pay for the company’s services.

“I think Northern Light is really trying to manage its entire system in a way that will not only make it competitive, but also meet the needs of people living in those rural areas,” Woloson said. “This might be a way to do that.”

Still, she said, “I do have concerns about this. How are people going to know whether the TeamHealth person is in-network and whether they will be billed for services? Maine does have some protections, but they’re not necessarily foolproof.”

Founded in 1979, TeamHealth has grown into one of the country’s largest physician staffing companies. It has more than 12,000 workers in a range of medical fields, including hospital and emergency medicine, primary care and anesthesia. 

In 2016, the private equity firm Blackstone acquired it for $6.1 billion, according to Reuters.

Under the new contract, it will become the employer of two types of providers at the four hospitals in Blue Hill, Ellsworth, Pittsfield and Waterville: ER clinicians and hospitalists. The latter are doctors who provide a mix of inpatient services. The new staffing arrangements will start to take effect around the beginning of February, according to Northern Light, and TeamHealth is already advertising physician openings at the Maine hospitals.

TeamHealth will also start working with other hospitals in the $1.7 billion network, including its flagship campus, Northern Light Eastern Maine Medical Center in Bangor. It may submit a proposal to staff three other Northern Light hospitals in Portland, Greenville and Presque Isle Maine in the coming months.

Northern Light says the new arrangement is a win-win. Administrators think the practices TeamHealth has developed over decades of operation will help trim costs, improve patient care and give the hospitals more flexibility to fill staff openings, allowing them to keep serving the rural residents who depend on them.

(MaineWriter- Northern Light says the TeamHealth contract will help trim costs.  Sure....trim costs for the hospital provider by allowing for a transfer of the expense to an out of network contractor....hospital cost shifting has now reached a new plateau.)
“We don’t know all things, in all areas. Nobody does. So this is an example of a strategic partnership between Northern Light Health and TeamHealth,” Steven Berkowitz, Northern Light’s senior vice president and chief physician executive, said. “This is what they do, and they do it well. They can bring experiences from literally hundreds of emergency departments across the country: what’s worked, what hasn’t worked. So I’m very excited about them taking a very comprehensive look at what we’re doing and what can we do to be even better.”

While Berkowitz said Northern Light providers already deliver strong care, he said TeamHealth has systems for measuring performance that will help it find efficiencies and improve a number of outcomes, such as hospital readmissions and how long patients must wait to be seen.

Another reason Northern Light is pursuing the new arrangement is because it’s had to pay for temporary doctors, known as locum tenens physicians, to fill openings in recent years.

That interim staffing can cost a hospital more than twice as much as full-time employees, given the travel and other expenses they require, but TeamHealth has a nationwide network of doctors it can draw to Maine at less expense and with less hassle, according to Berkowitz.

At least one of the system’s hospitals, Northern Light Maine Coast Hospital in Ellsworth, has struggled with physician turnover and staffing costs since joining the system in 2015.

Last year, a group of doctors left after the parent organization made controversial changes to their contracts, according to the Ellsworth American. The hospital’s reliance on costly locum tenens doctors has contributed to millions in operating losses over the last few years, its president told the Ellsworth American in December. It projects a $4 million loss this year, after even greater losses in 2016 and 2017.

Out-of-network bills
While the new arrangement may help Northern Light’s bottom line, it remains to be seen whether patients will feel the same way about their own wallets.

When TeamHealth and another physician staffing company, EmCare, entered hospital ERs between 2011 and 2015, their entrances were associated with a jump in out-of-network billing, though the change was more dramatic under EmCare, according to the study published in March 2018 by researchers at Yale University.

Using data provided by an unidentified health insurance company, the researchers found that under EmCare, there was an 81 percent hike in the portion of visits by that insurer’s customers that led to an out-of-network bill, compared with 33 percent under TeamHealth.

The study also found that TeamHealth’s arrival raised the price of emergency care in another way. Several months after the company’s doctors went out-of-network, many of them negotiated to re-enter the insurance network and received in-network rates 68 percent higher than they had received previously, the researchers found.

“This is an example of the firm using a now-credible threat of out-of-network billing to gain bargaining leverage in their negotiations over in-network payments,” the authors wrote.

Some consumer advocates and academics have assailed the practice of balance billing, saying it blindsides patients who can’t control which doctors see them in a hospital or know what those private doctors have negotiated with insurance providers, according to past reporting by The New York Times.

For U.S. patients who learn they must pay out-of-network medical bills, the damage can be severe.

Those bills range in price from hundreds of dollars to more than $19,000, according to a 2016 study from Yale University. Using insurance company data, that research found about one in five emergency room visits nationwide led to an out-of-network bill, although the practice didn’t appear to be common in Maine.

“To put it in very, very blunt terms: This is the health equivalent of a carjacking,” Zack Cooper, an assistant professor of health policy and economics at Yale, told The New York Times. He co-authored both the recent study on staffing companies such as TeamHealth and the earlier one on out-of-network billing.

A group representing ER doctors, the American College of Emergency Physicians, pushed back on some of those findings, saying they overstate the risk of balance billing. It argued that insurers are the ones who have failed to offer reasonable in-network rates.

In Maine, patients at the four Northern Light hospitals will soon learn whether it’s a problem here.

A TeamHealth spokeswoman didn’t directly respond to questions about whether the company plans to enter the insurance networks accepted at those hospitals, but she left open the possibility that the company could send out-of-network bills to Maine patients.

TeamHealth works “diligently to negotiate fair market rates with managed care plans and payers before beginning services at any client facility,” the spokeswoman, Natalie Bullock, wrote in an email. “If/when TeamHealth clinicians are out-of-network at a particular hospital and/or facility, we do everything we can to avoid out-of-network payment for the physician services portion of a patient’s bill. When out-of-network payment is unavoidable, we work closely with patients and families to reach amicable payment solutions.”

At Northern Light, Berkowitz said he doesn’t expect any major insurance changes for patients under the new arrangement.

“When they come to our ER or get admitted to our hospital, whatever insurance they have with us, the same things would occur, the same things would” be covered, Berkowitz said. “Now, could there be some unusual insurance arrangement with some insurance company? I guess it could, but the intent is to make this seamless.”

“And I want to know if there is an issue like that,” he added. “Our intent is not to somehow or another pass on more costs to a patient, or something like that.”

Berkowitz said that he was not aware of any terms in TeamHealth’s contract that would prevent the contractor from going out of network, and he doesn’t expect patients to be notified if they’re seeing a doctor not directly employed by Northern Light. He referred most questions about future billing to TeamHealth.

Kevin Lewis, president and CEO of one of Maine’s health insurers, the nonprofit Community Health Options, said in late December that he wasn’t aware of any negotiations the insurer has had with TeamHealth. He said he couldn’t comment on how any negotiations with the company might go.

“We certainly value our partnership with Northern Light and its system of hospitals,” he said. “These are important access points. We certainly look to ensure good access to care.”

In Maine, patients have some protections against the costs that can come from visiting an out-of-network doctor at a facility that otherwise accepts their insurance.

One law that took effect at the start of 2018 requires insurers to pay for non-emergency medical services provided by out-of-network providers if the patient had reason to believe the provider was in network and covered by the insurer. It also mandates that insurance companies in the state offer accurate, online directories of providers in each plan that they update monthly.

That law applies to services provided by hospitalists, one of the types of physicians that will be employed by TeamHealth under its new deal with Northern Light, Judith Watters, a consumer outreach specialist at the Maine Bureau of Insurance, wrote in an email.

Another state law requires that health plans subject to terms in the federal Affordable Care Act pay in-network rates for emergency medical costs even if an out-of-network provider provides those services.

Watters said that Mainers can report any concerns about medical billing or claims to the consumer health care division of the Maine Bureau of Insurance by calling 800-300-5000.

However, even in states that have passed comprehensive laws protecting against balance billing, there are gaps that have allowed the practice to persist, according to a 2017 analysis by the Commonwealth Fund.

Woloson, from Maine Consumers for Affordable Health Care, questioned whether Maine’s laws would ensure that all services provided by TeamHealth physicians are covered if the physicians are outside the accepted insurance networks.

“It’s not clear how expansive the scope of care is that their doctors will be providing in hospitals,” she said. “If this news is out, that TeamHeath has providers out working in hospitals, there could be an argument that if someone is billed by an out-of-network provider, that it might not be considered surprise billing, especially if it happens more than once.”
For-profit care?

While roughly two-thirds of U.S. hospitals have outsourced the staffing of their ERs, according to the recent Yale study, there are few precedents for it in the Pine Tree State, according to Charles Pattavina, an emergency physician at St. Joseph Hospital in Bangor who recently served as that hospital’s medical director and chief of emergency medicine.

Pattavina — a recent president of the Maine Medical Association who has been on the national board of the American College of Emergency Physicians — isn’t aware of any other Maine systems that have outsourced at the level of Northern Light.

The American College of Emergency Physicians has challenged the view that ER doctors are to blame for out-of-network billing, arguing that patients would fare better if their insurers offered more reasonable rates and more comprehensive provider networks.

Speaking for himself, Pattavina said the recent findings on TeamHealth by the Yale researchers were sound, but he disagreed with the premise that there was something unseemly about the company’s reported practice of threatening out-of-network coverage to secure higher in-network rates.

“That’s just business,” he said. “They can play hard ball with the insurance company. You would hope they play hard ball together.”

However, Pattavina raised other concerns about the entry of a large, outsourcing company into Maine’s ERs. For one thing, he said that a hospital has less control over the quality of its physicians when a contractor takes over.

Pattavina knows talented physicians who have worked in Northern Light hospitals. He also knows good doctors who have worked for TeamHealth and said that in the best cases, staffing companies can bring well trained clinicians to hospitals that need them. The danger, he said, is that existing physicians may refuse to work for the company and be replaced by less qualified providers.
At Northern Light, Berkowitz disagreed with the notion that TeamHealth providers could be less qualified and said they all will have to meet the same standards Northern Light sets for its own staff.

“They have very high credentialing. They have very high standards, and I see nothing but the top quality ER docs and hospitalist docs,” he said. “That’s totally unfounded in anything that I’ve experienced knowing TeamHealth for many years. An organization like TeamHealth has a very extensive credentialing process, as does Northern Light Health. They’re both excellent.”

TeamHealth had a similar response. “All clinicians placed by TeamHealth in the hospital are subject to rigorous screening and credentialing guidelines established by the hospitals in conjunction with TeamHealth,” spokeswoman Bullock wrote in an email.

Pattavina was also skeptical that TeamHealth could find efficiencies across Northern Light without cutting services or raising prices.

Northern Light is classified as a nonprofit organization. But Pattavina noted that as a for-profit company owned by the investment firm Blackstone, TeamHealth is likely trying find a buck somewhere in the deal. The ways it could do that, he said, include cutting positions, paying lower wages or increasing billing, either directly from patients or indirectly from insurers.

“They wouldn’t be in it if they didn’t think they were going to make money,” Pattavina said. “It’s got to come from somewhere, because at the end of the day, Blackstone expects to make money.”

Asked how the company’s profit motive could affect Maine hospital care, Bullock responded, “TeamHealth’s number one priority is patient safety and delivering high-quality care to patients and families.” The company didn’t make any representatives available for an interview.

Staffing levels

Representatives from TeamHealth and Northern Light didn’t respond to specific questions about how staffing or employment contracts will change under the new partnership. But Berkowitz said staffing will be one of the factors TeamHealth considers when it’s looking for efficiencies.

“Do we have enough doctors, nurses?” he said, as an example of a question he hopes TeamHealth can answer. “Could we have too many doctors? What’s the best way to do that? So we want to rely on them for national models for logistics. … It’s not less care. That’s just not an option. But efficiencies are made by throughput and the ability to make time better spent.”

Some physicians who now work for Northern Light declined to speak publicly about TeamHealth’s plans.

But a semi-retired ER doctor who used to work at what’s now Northern Light Inland Hospital in Waterville said he disagrees with a staffing change that could be near.

Over a career in family and emergency medicine, John Garofalo, 64, of Belgrade has worked at several Maine hospitals. From early 2016 to late 2017, he said he worked full-time in the emergency department of what was then Inland Hospital, before taking another job at St. Joseph Hospital in Bangor.

Although Garofalo enjoyed working at Inland and praised his colleagues there, he couldn’t agree on a new contract with the parent organization that’s now Northern Light. After tiring of the commute to Bangor, though, he signed a new contract to return to Inland on a per diem basis, he said.

Before Garofalo could start, his hiring was put on hold and he was offered a new contract to work for TeamHealth, he said.

However, he refused to sign it because he didn’t agree with a stipulated change in ER staffing. A physician would still be stationed there at all hours of the day, but TeamHealth was proposing to eliminate a second clinical worker — usually a nurse practitioner or physician assistant — who also staffed the emergency department from around 10 a.m. to 8 p.m., according to Garofalo.

While Garofalo doesn’t know much about the quality of TeamHealth’s offerings, he thought the arrangement could prove lacking if the emergency department was inundated. If a doctor was tied up with something serious, he said, the lack of a second worker could force other patients to wait for care.

“The quality of care at Inland is very good. What I’m saying is, this circumstance could lead to a potential for compromise of that,” he said, noting that he was just sharing his personal opinion and hadn’t heard of any actual problems.

“Possibly you may have a patient who is critically ill and you can’t leave the bedside. Does that happen every day? No, but when it does happen, it can lead to real problems in terms of providing care in a timely manner. … I’m not saying I think anything bad has happened, but the potential for it goes up.”

Asked about Garofalo’s concern, a spokeswoman for Northern Light, Karen Cashman, wrote in an email that the organization doesn’t share specific staffing numbers.

Individual “hospitals are staffed based upon historical data with a back-up plan always in place for unforeseen or emergency situations,” she wrote. “We remain comfortable that TeamHealth, as a nationally recognized outcomes-based provider with a demonstrated track record, has developed an appropriate model that will serve our hospitals well.”

Bullock, the TeamHealth spokeswoman, wrote in an email that the company couldn’t comment on specific employment contracts.