With medical costs continuing to rise along with the uncertainty about the future of health insurance coverage, new research shows more Americans are going without the health care they need.

A survey released Wednesday from Bankrate.com found that one in four American families have not sought medical care because they couldn't afford it. Thirteen percent of respondents had no insurance, while the rest had a mix of employer-sponsored, individual and Medicaid coverage. The bulk of uninsured respondents were millennials. Younger, healthier people traditionally go without coverage.

However, "Even insured people found co-pays and deductibles far less affordable than they expected," said Robin Saks Frankel, credit card analyst at Bankrate.com

Two years ago, a Kaiser Family Foundation study found that only three in five households have enough set aside to meet an individual deductible of $1,200 or a family deductible of $2,400. Only about half of U.S. households had enough money to cover higher deductibles than those.

Play Video

President Obama's former economic adviser Austan Goolsbee joins CBSN to discuss the costs of the American Health Care Act, the GOP's replacement ...

Health care advocates and economists agree that forgoing health care can have devastating long-term consequences. It can mean patients get sicker and require even more expensive treatment when they end up in the emergency room. These types of unexpected medical bills can lead to a huge financial burden for the patient that could take years to pay off, said Frankel.

If you're struggling with medical costs or skipping the care you need, here are four strategies that may help make your health care more affordable.

Schedule your annual physical. If you have insurance, there's no reason to skip this important appointment. Under the Affordable Care Act, annual physicals are 100 percent covered. That means no co-pay, and your deductible doesn't have to be met beforehand. Spotting medical problems while they're small can prevent big problems (and bigger medical bills) down the road. If your physical yields some unwelcome results, you can talk to your doctor about the cost of future diagnostics and care. See the next item.

Don't be afraid to negotiate. If you're due for an expensive test, procedure or a series of doctor visits, be sure to ask about the price and your out-of-pocket costs ahead of time. You can research the costs at various labs and facilities in your area at websites such as Healthcare Bluebook. Then talk to your doctor or insurer about what you've found and how you can get a lower price. Separately, your doctor may offer payment plans or discounts for extended treatments. Be sure to ask.

Play Video

President Trump is pushing Republican senators to get on board with the legislation passed by the House to roll back Obamacare, but key Republica...

When you do receive a medical bill, review it carefully. Always make sure it's itemized, and check for errors. All health care providers use special billing codes, so mistakes can easily creep in. If you suspect you've been overcharged or mischarged for something, check with your provider and your insurer.

Pay less for prescription drugs. For many people, medication is the biggest health expense. Consider ordering regular, long-term medicines in bulk for lower prices. For less frequent medications, shop for the best prices in your area using comparison websites such as GoodRx. And always discuss any possible generic alternative with your doctor. Low-income patients should check with drug companies directly for any prescription relief programs they may offer, especially for expensive specialized drugs.

Sign up for your FSA or HSA. If your employer offers a Flexible Spending Account or Health Savings Account, be sure to take advantage. For an FSA, your contributions are made pretax, and the money can be used, among other things, for co-pays and health expenses before your deductible. HSAs are used if you have a qualifying high-deductible insurance plan. Contributions are also pretax, and no tax is paid when money is withdrawn for qualified medical expenses. Employers often contribute to workers' accounts as an incentive to get them to sign up for high-deductible health plans.

2017 CBS Interactive Inc.. All Rights Reserved.

Go here to see the original:

Are you skipping that doctor visit or pill you need? - CBS News

It is an old joke among health-policy wonks that what the American people really want from health-care reform is unlimited care, from the doctor of their choice, with no wait, free of charge. For Republicans, trying to square this circle has led to panic, paralysis, and half-baked policy proposals such as the Obamacare-replacement bill that passed the House last month. For Democrats, it has led from simple disasters such as Obamacare itself to a position somewhere between fantasy and delusion.

The latest effort to fix health care with fairy dust comes from California, whose Senate voted last week to establish a statewide single-payer system. As ambitious as the California legislation is, encompassing everything from routine checkups to dental and nursing-home care, its authors havent yet figured out how it will be paid for. The plan includes no copays, premiums, or deductibles. Perhaps thats because the legislatures own estimates suggest it would cost at least $400 billion, more than the states entire present-day budget. In fairness, legislators hope to recoup about half that amount from the federal government and the elimination of existing state and local health programs. But even so, the plan would necessitate a $200 billion tax hike. One suggestion being bandied about is a 15 percent state payroll tax. Ouch.

The cost of Californias plan is right in line with that of other recent single-payer proposals. For example, last fall, Colorado voters rejected a proposal to establish a single-payer system in that state that was projected to cost more than $64 billion per year by 2028. Voters apparently took note of the fact that, even after figuring in savings from existing programs, possible federal funding, and a new 10 percent payroll tax, the plan would have still run a $12 billion deficit within ten years.

Similarly, last year Vermont was forced to abandon its efforts to set up a single-payer system after it couldnt find a way to pay for the plans nearly $4 trillion price tag. The state had considered a number of financing mechanisms, including an 11.5 percent payroll tax and an income-tax hike (disguised as a premium) to 9.5 percent.

On the national level, who could forget Bernie Sanderss proposed Medicare for All system, which would have cost $13.8 trillion over its first decade of operation? Bernie would have paid for his plan by increasing the top U.S. income-tax rate to an astounding 52 percent, raising everyone elses income taxes by 2.2 percentage points, and raising payroll taxes by 6.2 points. Of course, it is no surprise that Medicare for All would be so expensive, since our current Medicare program is running $58 trillion in the red going forward.

It turns out that free health care isnt really free at all.

How, though, could a single-payer system possibly cost so much? Arent we constantly told that other countries spend far less than we do on health care?

It is true that the U.S. spends nearly a third more on health care than the second-highest-spending developed country (Sweden), both in per capita dollars and as a percentage of GDP. But that reduction in spending can come with a price of its own: The most effective way to hold down health-care costs is to limit the availability of care. Some other developed countries ration care directly. Some spend less on facilities, technology, or physician incomes, leading to long waits for care. Such trade-offs are not inherently bad, and not all health care is of equal value, though that would seem to be a determination most appropriately made by patients rather than the government. But the fact remains that no health care system anywhere in the world provides everyone with unlimited care.

Moreover, foreign health-care systems rely heavily on the U.S. system to drive medical innovation and technology. Theres a reason why more than half of all new drugs are patented in the United States, and why 80 percent of non-pharmaceutical medical breakthroughs, from transplants to MRIs, were introduced first here. If the U.S. were to reduce its investment in such innovation in order to bring costs into line with international norms, would other countries pick up the slack, or would the next revolutionary cancer drug simply never be developed? In the end, there is still no free lunch.

American single-payer advocates simply ignore these trade-offs. They know that their fellow citizens instinctively resist rationing imposed from outside, so they promise unlimited care for all, which is about as realistic as promising personal unicorns for all. In the process, they also ignore the fact that many of the systems they admire are neither single-payer nor free to patients. Above and beyond the exorbitant taxes that must almost always be levied to fund their single-payer schemes, many of these countries impose other costs on patients. There are frequently co-payments, deductibles, and other cost-sharing requirements. In fact, in countries such as Australia, Germany, Japan, the Netherlands, and Switzerland, consumers cover a greater portion of health-care spending out-of-pocket than do Americans. But American single-payer proposals eliminate most or all such cost-sharing.

Adopting a single-payer system would crush the American economy, lowering wages, destroying jobs, and throwing millions into poverty. The Tax Foundation, for instance, estimated that Sanderss plan would have reduced the U.S. GDP by 9.5 percent and after-tax income for all Americans by an average of 12.8 percent in the long run. That is, simply put, not going to happen. So Americans are likely to end up with a lot less health care and than they have been promised.

Santa Claus will always be more popular than the Grinch. But the health-care debate needs a bit more Grinch and a lot less Santa Claus. Americans cannot have unlimited care, from the doctor of their choice, with no wait, for free. The politician that tells them as much will not be popular. But he or she may save them from something that will much more likely resemble a nightmare than a utopian dream.

Michael Tanner is a senior fellow at the Cato Institute and the author of Going for Broke: Deficits, Debt, and the Entitlement Crisis. You can follow him on his blog, TannerOnPolicy.com.

More:

Embracing the Hard Realities of Health-Care Reform - National Review

CINCINNATI Continuing the White House's infrastructure week, President Donald Trump took his pitch for rebuilding America to the very people that elected him on Wednesday.

With the Ohio River as his backdrop, Trump marketed his plans as a crucial step to rebuilding a crumbling U.S infrastructure system.

"It's time to recapture our legacy as a nation of builders," Trump said. "And to create new lanes of travel, commerce and discovery."

The future, he predicted, was going to be "beautiful and the future's going to be bright."

"Together we will fix it," the president promised corporations and citizens gathered on the banks of the Ohio. "We will create the first class infrastructure our country and our people deserve."

Related: Both Parties Say Trumps Infrastructure Plan Needs Repair

Trump also pushed another legislative priority: repealing and replacing Obamacare.

Obamacare, Trump said, is "crashing. It's dead, it's in a death spiral."

He blamed Democrats for obstructing the long promised Republican repeal and replace of the Democrats' signature healthcare law, calling them "obstructionists" and lamenting the lack of bipartisanship on "every single thing."

Hours earlier, Adm. Michael Rogers, the director of the National Security Agency, and Daniel Coats, the director of national intelligence, refused during a Senate Intelligence Committee hearing Wednesday to confirm or deny allegations that Trump asked them to interfere in the FBI's probe into Moscow's interference in the 2016 elections.

Trump also surprised some White House staff and Hill lawmakers alike Wednesday by tweeting news that Chris Wray, a former DOJ assistant attorney general and New Jersey Gov. Chris Christie's personal attorney during the "Bridgegate" scandal, to replace ousted FBI Director James Comey.

One White House official, speaking on condition of anonymity, told NBC News most of us learned about it from the tweet.

Asked soon after the presidents tweet if there would be a public announcement to come, Principle Deputy Press Secretary Sarah Huckabee Sanders told NBC News the president just did it, referring to the tweet.

The White House released an official announcement on Wednesday afternoon.

The nature of Trumps tweets have come under scrutiny of late, with Press Secretary Sean Spicer telling reporters Tuesday that the presidents tweets should be taken as official statements.

Wednesday's "infrastructure week" stop on the Ohio River dovetailed with a push Monday from the White House to privatize Air Traffic Control, separating the entity from the Federal Aviation Administration and making it a non-government non-profit.

We will work directly with state and local governments to give them the freedom and flexibility they need to revitalize our nations infrastructure, he said.

Trump, who is often touted by his vice president as a builder, will stress his campaign promises to rebuild America on Thursday when he meets with state and local leaders to discuss the need for an increased focus on roads and bridges.

That same day, Comey will testify on Capitol Hill.

As Trump wrapped his infrastructure push, Comey's prepared remarks went live online.

Some supporters in Cincinnati, however, scoff at the focus on Comey's testimony and continued media coverage of probes into whether there was improper communication between Trump officials and Russia during the 2016 campaign.

Alex Adams, 19, agreed, discarding "this fake Russian story that there was collusion" and said he was "ticked off" by attempts to discredit Trump's powered-by-the-people win.

Randy Chrisman told NBC News on Wednesday he's "disappointed" that there are "so many distractions" from the Trump is trying to do.

Trump's tweeting can sometimes do more harm than good, some supporters say.

"Sometimes it would be good if he said less, maybe, on Twitter," Chrisman said. "But that's what he chooses to do."

The concern for Chrisman and supporters like him, however, remained squarely on infrastructure.

"You know, we've built some really good things but keeping up with it and keeping the maintenance of it - some of its really hurt the system," he said, anxious to hear what Trump would propose.

Read the original post:

Trump Pivots to Health Care, Infrastructure on Eve of Comey Hearing - NBCNews.com

H

ow to rein in the escalating cost of health care is generating fierce debate across the U.S. Most politicians and health care professionals are focusing on big targets like legislation and the pharmaceutical industry. But the savings were all looking for may well come from far smaller sources, like the personal health devices that many Americans have so readily adopted.

About half of all Americans have one or more chronic conditions heart disease, diabetes, kidney disease, arthritis, and asthma, to name a few. Many chronic conditions arise from unhealthy lifestyles that include the usual suspects: poor diet, little or no exercise, and stress. These conditions account for the majority of deaths in the United States, and up to 86 percent of health care expenditures.

Look at diabetes as an example. Nearly 30 million Americans are now living with diabetes, and another 86 million have prediabetes, a higher-than-normal blood sugar level that can lead to diabetes. This disease accounts for unnecessary loss of vision, amputations, heart disease, kidney damage, and premature death. It also costs Americans $245 billion a year. But chronic diseases like diabetes need not take such huge personal or economic tolls. Easily implemented changes that digitize components of health and health care can lighten the load for people, their doctors, and the country at large.

advertisement

Millions of Americans currently use devices to monitor their health and fitness. These include scales, activity monitors (Fitbit, Apple Watch, Microsoft Band, and the like), heart rate and blood sugar monitors, and more. The data they record can help people take more control over their health and lifestyles. They can also help doctors keep track of their patients health, as information from these devices can be uploaded into electronic health records. Data from such devices could also alert doctors or first-aid workers to a problem that requires immediate attention, like a stroke or heart attack.

Fitbit likely wont improve your health, study says

Personal health devices are already or soon will be sophisticated enough to detect medical conditions. For instance, if your fitness device indicates that your usual activity level has fallen off but your heart rate is higher than usual, it could be a sign that you are coming down with the flu or other infectious disease.

To be sure, the jury is still out on how effective these devices will be. According to one randomized trial, Fitbit wearers did indeed exercise more but not enough to ensure weight loss and improved fitness the keys to battling chronic diseases.

On the other hand, at least 21 ongoing studies are examining how the Fitbit activity tracker could be used to help make cystic fibrosis patients healthier, to diagnose and treat chronic obstructive pulmonary disease, to help teens stop smoking, and more. A trial by Takeda Pharmaceuticals and Cognition Kit is using Apple Watches and Microsoft Bands to monitor physiological signs for indications of oncoming bouts of depression. Poole Hospital in the United Kingdom and its partners are developing a solution using the Band to provide more effective care for people with epilepsy.

For many users, these devices are a fun way to keep track of their performance. Users can connect with and compete with friends, and give themselves pats on the back via badges and positive feedback. In effect, the devices and their associated apps can gamify personal health and fitness.

But whats fun for users could also help curb health care spending. Offering users of personal health devices more tangible incentives, like cash or discounts on health insurance, could encourage more physical activity the most important way to prevent and treat many chronic lifestyle-related diseases.

Employers and insurers are already trying this approach. Under a provision of the Affordable Care Act, employers can offer wellness incentives to their employees (paid for by insurers) if they agree to wear a fitness tracker or pedometer or use a fitness app to record their activity. Incentives such as gift cards and rate discounts are available through some national insurers. UnitedHealthcare, for example, offers employees covered through some of its plans up to $4 a day for meeting certain daily walking goals.

Two years in, what has Apple ResearchKit accomplished?

There is, of course, a potential downside to collecting such personal data. One concern is that smart devices could be used to determine if an individual has a preexisting condition maybe even one he or she wasnt aware of. A company could use that information to dump the individual as a customer or place him or her into a high-risk and high-cost customer pool. Health data collected by an employer as part of a wellness program, or by an insurance company as part of an incentive program, may not be subject to the same privacy laws as health data collected by doctors or hospitals. This information is held in databases that dont necessarily have the same security regulations as electronic health records. It could be sold or hacked.

Employers could also use data from fitness devices to weed out unhealthy employees who might end up costing them more money because of chronic lifestyle-related diseases. And if an employer decides to adopt the gamification approach and make fitness a group effort, it could subject employees to fat shaming, or even discrimination penalizing employees for pounds causing extra stress and possibly contributing to unhealthy lifestyle behaviors and the lack of motivation the program was supposed to resolve.

I believe that despite the dearth of overwhelmingly convincing data on the effectiveness of personal health monitors and their inherent risks, the health industry will turn to them as a way to reduce costs. It must do something. U.S. employers currently insure about 170 million people and spend, on average, more than $12,500 in premiums for each employee and his or her family. By 2025, that figure will reach $24,500. A big chunk of that bill is due to preventable chronic diseases.

Activity trackers and other devices can motivate their users to live healthier lifestyles, especially as technology improves to become more precise and accurate (were not quite there yet). Incentives to use these devices are likely to grow, though employers, insurance companies, and health care providers will have to convince people that the data generated by the devices wont be used against them.

This digital health care revolution may not be the all-encompassing solution to the tsunami of chronic disease that threatens to break the health care bank, but it is one that can doubtlessly have a great and lasting impact.

Yiftah Ben Aharon is co-founder and CEO of GlucoMe, a digital diabetes clinic.

Yiftah Ben Aharon can be reached at yiftah@glucome.com

Trending

The Real World, Diabetes: As cameras roll at a

The Real World, Diabetes: As cameras roll at a Jamaican resort, desperate patients seek healing

The growing diet divide between rich and poor in

The growing diet divide between rich and poor in America

Uterus transplants are no match for the safety of

Uterus transplants are no match for the safety of surrogacy

Recommended

Its time to get serious about the safety of

Its time to get serious about the safety of medical devices

Does Medicares free annual wellness visit do any good?

Does Medicares free annual wellness visit do any good?

We need more data sharing to improve cancer treatment

We need more data sharing to improve cancer treatment

See the rest here:

Small wearable devices may lead to big health care savings - STAT

6

Let friends in your social network know what you are reading about

The USA TODAY NETWORK will have live coverage of this event.

Try Another

Audio CAPTCHA

Image CAPTCHA

Help

CancelSend

A link has been sent to your friend's email address.

A link has been posted to your Facebook feed.

USA TODAY 12:46 p.m. ET June 7, 2017

President Trump(Photo: Evan Vucci, AP)

The theme of President Trump's trip to Cincinnati today was supposed to be his plan to shore up America's infrastructure, but his list of talking points is getting crowded.

The president announced on Twitter this morning that he'll also meet with "ObamaCare victims" and will discuss health care. Watch the president's speech live in the player above.

Later, White House officials indicated he'd talk jobs and energy, too, and would surround himself with coal miners and steel workers in hard hats.It's also possible the president could talk about his troubles back in Washington, where former FBI Director James Comey is set to testify Thursday before Congress.

Read or Share this story: https://usat.ly/2sTyIOx

Read more here:

Live stream: Trump discusses health care during Ohio visit - USA TODAY

Health care presents one of the biggest opportunities for startups--as well as some of the biggest frustrations. The market size and the potential to make an impact in people's lives are nearly unrivaled, as is the level of regulation. Still, in 2016, venture investors poured $12.2 billion into health care, backing companies that promise to change everything from cancer care to the process of finding a new doctor. Here are some of the standouts.

Flatiron founders Zach Weinberg (left) and Nat Turner.

CREDIT: Saskia Uppenkamp

Google Ventures-backed Flatiron Health has developed a cloud-based technology platform that's currently used by about 260 cancer clinics. The New York City startup takes the patient data it collects from those centers--without identifying details, of course--and shares it with pharmaceutical companies and researchers. The company raised an $8 million series A round in 2013. A little more than a year later, it raised $130 million, and a year after that, an additional $175 million, bringing its valuation to about $1.2 billion. Flatiron is one of fewer than a dozen billion-dollar-valuation "unicorn" companies in the health care space.

Major Investors: Google Ventures, First Round Capital, Roche, Allen & Co.

CREDIT: Courtesy Company

Freenome, headquartered in South San Francisco, is one of a slew of so-called liquid biopsy (i.e., blood test) companies to break out over the past few years. The goal is to use a patient's DNA, rather than a tissue sample, to diagnose cancer. Freenome says its tests do better than the current options for diagnosing prostate, breast, colorectal, and lung cancers. The company is using a $65 million round of funding, led by Andreessen Horowitz, to head into clinical trials.

Major investors: Andreessen Horowitz, Founders Fund, Charles River Associates

CREDIT: Courtesy Company

Another health care unicorn, Clover Health is an insurance start-up aiming to use data science to improve preventive medicine. The San Francisco-based company tracks dozens of clinical and social data points to help elderly and low-income patients avoid hospital visits. It currently handles claims for about 25,000 Medicare Advantage patients in New Jersey. With a recent $130 million funding round from Google Ventures and other backers, Clover plans to expand, and begin operations in three more states by this fall.

Major investors: First Round Capital, Sequoia Capital, Greenoaks Capital

CREDIT: Courtesy Company

New York City-based ZocDoc allows users to find in-network health care providers, book appointments online, and read reviews from other patients. About 6 million patients in the U.S. use the service each month. Providers pay a subscription fee to be listed, and then ZocDoc integrates with their practice management software. ZocDoc recently added a feature that lets patients type in their symptoms using natural language and then matches them with an appropriate provider, such as a doctor, dentist, nurse practitioner, or physical therapist. The company has raised a total of $223 million.

Major investors: Amazon founder Jeff Bezos, Khosla Ventures, Goldman Sachs

CREDIT: Courtesy Company

In 2013, the FDA ruled that genetic-testing company 23andMe, which has raised a total of $233 million, could no longer sell one of its signature services: test results that indicate a person's propensity to develop inherited diseases. Since then, Mountain View, California's 23andMe has mainly been using its genetic testing services to provide information about ancestry and origin. But in April of this year, the company finally won FDA approval to sell direct-to-consumer tests that provide genetic health risk information for conditions such as Parkinson's, Alzheimer's, and hereditary thrombophilia.

Major investors: Google Ventures, New Enterprise Associates, WuXi Healthcare Ventures

CREDIT: Courtesy Company

London-based Babylon Health, which has raised a total of $85 million, started as a telemedicine company, enabling doctors to make diagnoses via video and allowing patients to rate the quality of each interaction. But it's received more notice lately for another program it's piloting in the U.K.: an AI-powered chatbot that analyzes a patient's condition against a database of symptoms, while incorporating the patient's own medical history and responses to the chatbot's questions.

Major investors: Vostok New Ventures, Hoxton Ventures, Mustafa Suleyman

Read more:

The 6 Hottest Startups in Health Care - Inc.com

New York Times

Ossoff and Handel Joust Over Health Care and Who's the Real Georgian New York Times Channeling Democrats' determination to make health care a central issue in congressional elections, Mr. Ossoff aggressively went after Ms. Handel for the House-backed health care bill, which he said guts protections for Americans with pre-existing ... Ossoff, Handel Get Into Highly Charged Debate Over Health CareTPM Livable wages, health care lectures: The most striking 6th District debate momentsAtlanta Journal Constitution (blog) all 217 news articles »

Excerpt from:

Ossoff and Handel Joust Over Health Care and Who's the Real Georgian - New York Times

Forbes

Why UnitedHealth Rules Among Health Care Stocks Forbes Never mind that the Republican-controlled Congress can't seem to get its act together to repeal, much less replace, the Affordable Care Act, more popularly known as Obamacare. But health care stocks are doing just fine, in spite of the continued ...

See original here:

Why UnitedHealth Rules Among Health Care Stocks - Forbes

In the beginning, there was Obamacare. Since January, weve seen repeal and replace, repeal and repair, a draft American Health Care Act, a near-vote in the house, two new amendments, an actual vote in the house, and now whispers about the Senates rewrite, which should become public any day now.

Its just one of 2017s little surprises that when were feeling overwhelmed and confused, Twitter can be the cure. (Im still trying to process that, but it seems to be true.) If you follow a few knowledgeable folks, youll be able to keep track of whats actually happeningnot just with attempts to pass Trumpcare, but also the ways our current administration is sabotaging the Obamacare markets to manufacture a crisis. Here are my top picks:

Andy Slavitt knows more than probably anyone else about how Obamacare workshe was in charge of it for most of two years, as the administrator of the Centers for Medicare and Medicaid Services. Since Trump took office, Slavitt has dedicated his time to demystifying health care policy for the public. Hell speak at a town hall if your Republican congressperson wont hold one. And, most usefully for us, hes a great source of insider information on what lawmakers are talking about right now. Hes also on top of picking out obscure details of health care policy and explaining what their real-world effects will be.

Dan Diamond is a reporter for Politico, writing their daily Pulse newsletter about health policy and hosting the Pulse Check podcast. His feed is a good way to keep on top of health-related political newsincluding plenty of links from Politico, of course. A specialty of Diamonds is the brief, pithy statistic, like so:

Topher Spiro was part of the team that drafted the Affordable Care Act. Hes now the vice president for health policy at the Center for American Progress, a left-leaning think tank that publishes lots of analysis on whats going on with Obamacare and what could happen with Trumpcare. For example, theyre the folks who estimated people with cancer could end up paying $140,000 extra per year in premiums. Spiro keeps us up to date on analysis like this, and is another great source of threads that explain policy details in terms of what will happen in real life.

Kliff writes about health policy for Vox. On Twitter, she gives a big-picture view of health care laws across the country: not just Obamacare and Trumpcare, but also whats going on in state legislatures. She also shares a ton of explainers and maps from Vox and elsewhere.

Cox is the associate director of the Kaiser Family Foundation, where her job is figuring out how the ACA affects private insurance and their enrollees. If youve got insurance through your job and think the ACA didnt affect you because youre not on Obamacare, you need to read the kind of stuff Cox is talking about. Right now, thats the stability of insurance markets: Anthem may pull out of a lot of markets, leaving people in many areas with no insurer, because the Trump administration has threatened to cut off some of the ACAs mandated funding.

Following these people may not reduce your total intake of health care doom and gloom (and thats a bipartisan statement; everybody hates something about health policy these days), but theyll help you keep up on the important details that tend to get buried in news stories.

PS. Im sure I missed some great follows; please share your favorites in the comments so we can all learn together.

Read the original:

Follow These People on Twitter to Understand What's Happening With Health Care - Lifehacker

President Trump meets Tuesday at the White House with congressional Republican leaders -- anattempt to jumpstart efforts on overhauling ObamaCare, tax reform and other parts of his domestic agenda slowed by the Russia investigations and Capitol Hills notoriously long legislative process.

"Big meeting today with Republican leadership concerning Tax Cuts and Healthcare, Trump tweeted Tuesday morning. We are all pushing hard - must get it right!"

Under pressure to get at least one legislative victory in his first term, Trump is in fact meeting with the lawmakers twice Tuesday.

He will meet in the afternoon with GOP leaders of the House and Senate, then host a working White House dinner for a handful of Republicans members, White House legislativedirector Marc Shortsaid Monday.

However, Senate Republicans have already quickened the pace on ObamaCare, after being urged last week by Treasury Secretary Steve Mnuchin to vote this summer to increase the federal debt ceiling.

Sources told Fox News on Monday that the GOP-led Senate now wants to vote on ObamaCare as soon as possible so members can devote July to the debt-ceiling debate and September to tax reform, with the intent of providing tax breaks to voters.

Senate Republican leaders emerged Monday from their regular weekly meeting with the surprise announcement that they have a draft bill on overhauling ObamaCare and that a vote could happen as early as July 4.

Texas Sen. John Cornyn, the chambers No. 2 Republican, was among the more cautious about the timeline, saying a vote would come sometime in July.

The ObamaCare push in the Senate follows the House last month passing its version, which congressional analysts say would end health-care coverage for an estimated 23 million Americans.

Senate Republicans have met privately for weeks on the issue and say they will have their own legislation. However, they realize that any plan that cuts the deficit by billions will also likely mean less coverage, particularly for those with pre-existing medical conditions.

Sen. Richard Burr, R-N.C., in fact said last week that a vote on ObamaCare by the end of the year was unlikely.

Short also acknowledged Monday that congressional investigations -- like the two on Capitol Hill on whether the Trump campaign colluded with Russia in the 2016 elections -- detracts from the presidents agenda.

But theres been lots of progress we're pleased about this spring, he added.

Trump, a former real estate magnate, complained last month about the slow pace of the Senate.

It's an archaic system, he told Fox News. It's really a bad thing for the country."

Short also said Monday that he doesnt expect legislation on tax reform until after Labor Day and that an infrastructure deal would come by the end of the year but the administration has no firm timeline.

Excerpt from:

Trump tries to fire up tax reform, health care agenda amid turmoil - Fox News

(Jenny Starrs/The Washington Post)

Senate Republican leaders are aiming to conclude their perilous and divisive effort to rewrite the nations health-care laws as soon as late this month, giving themselves only weeks to resolve substantial disagreements and raising the possibility that their push will collapse.

The leadership team is eyeing a vote by the end of July on a bill to be completed by early that month, with some aspiring to wrap up even sooner, as they cast ahead to the other legislative priorities on the horizon. One said he expected to hold a vote on a bill even if it lacked the support to pass, underscoring a growing desire to bring a difficult debate to a close one way or the other.

Some Senate Republican aides and associates are already privately discussing how the GOP would craft its midterm campaign message if it fails to pass a health-care bill, suggesting they could tell voters they need to build a bigger majority to finally undo the Affordable Care Act, known as Obamacare, as they have long promised.

[The Health 202: Democrats arent winning the expectations game on health care]

There is also rising pessimism among rank-and-file Republican senators about the prospect of reaching consensus on legislation to make good on a signature campaign promise, highlighting the steep climb they face to securing the 50 votes they need to pass a it.

I still think in the end theres a huge reason why we have to get to 50 on this, said Senate Republican Conference Chairman John Thune (R-S.D.) on Monday. He added: Obviously, were going to have a vote one way or the other, but if we dont pass something and we go into 18, you know, its on us to try and get this fixed.

Thune said he hoped a vote could be taken during this work period, but stressed that it would be up to Majority Leader Mitch McConnell (R-Ky.) to decide when a vote would happen. The Senates next week-long recess begins at the start of July.

Senate Republican Whip John Cornyn (R-Tex.) said, We have to get this done by the end of the July because then we need to get on to taxes in the fall. He was referring to tax-code revisions, another legislative priority Republicans have established for themselves.

Cornyn and Thune made their comments as they walked in and out of a late-afternoon meeting in McConnells office that included other key GOP senators. The Kentucky Republican and his team are expected to present rank-and-file GOP senators with several potential policy options throughout the coming week, including at a weekly luncheon on Tuesday afternoon.

A little bird told me that something like that might be rolled out, Cornyn said. But, you know, weve been talking about this for seven years. And so now is the time to start coming up with some tangible alternatives and building consensus. So, suits me.

But agreement has been very difficult for Senate Republicans to achieve amid dissent over significant policies. The biggest issues they are trying to sort out: how Medicaid should be structured and funded, whether to allow states to avoid certain Obamacare regulations and how to craft tax credits to replace existing insurance subsides.

Senate GOP leaders could present options on these fronts this week as well as on repealing taxes in the ACA, according to several senior GOP aides. Its unclear when a physical draft of the bill will be produced.

Sen. Shelley Moore Capito (R-W.Va.), who represents a state that expanded Medicaid under the ACA, said as she walked into McConnells office that she would support a slower phaseout of Medicaid expansion than was established under the health-care bill that passed the House early last month. But she added: Im not saying I support phasing it out.

Thune has been looking at ways to adjust the tax credits in the House bill to offer more assistance to elderly and lower-income Americans.

It remains unclear, however, whether hard-line conservative senators will support such proposals in a final vote.

The differing ideas reflect not only contrasts in policy but sensitivities to opposite ends of the political spectrum, with some concerned about an electoral backlash from centrist or left-leaning voters who oppose major changes to Obamacare and others worried a less aggressive assault on the ACA will leave right-leaning opponents of the law dispirited.

All the behind-the-scenes work and discussion with those parameters in mind, however, has not generated confidence in some Republican senators. Some have openly doubted that the talks are leading anywhere positive.

Sen. Lindsey O. Graham (R-S.C.) said Monday that he doesnt think Republicans will pass a health-care bill in 2017, Bloomberg News reported. Over the Memorial Day recess, Sen. Richard Burr (R-N.C.) came to the same conclusion and Sen. Jeff Flake (R-Ariz.) said he doubted a bill could pass before the August recess.

There is a growing sense among Senate Republicans that they need to either pass a health care overhaul or move on to other ways of fixing the health-care system, possibly through a tax reform bill or in smaller bipartisan legislation later this year.

Some want to move on so that Congress can focus on pressing deadlines in the late summer and early autumn, including a vote to increase the federal borrowing limit that could come as early as mid-July. Republicans have also suggested that they want to begin negotiations with Democrats on a long-term spending bill before Sept. 30 when the fiscal year ends.

The small window for action and policy disagreements has upped the chatter among Senate GOP aides and associates that making good on their often-repeated promise to undo parts of Obamacare may not be possible. Many Republicans, including top aides working on the GOP health plan, said they need to vote on health care and move on by early July, even if that means voting on a bill that fails.

Quietly, people are preparing for a lot of possible outcomes and how to deal with them, said one Republican in frequent communication with Republican senators and staff, who like other aides and allies interviewed for this story were granted anonymity to speak candidly.

Much of the serious policy work has been conducted behind the scenes by a small group of health policy staffers, with members of McConnells inner circle leading the political strategy, according to top GOP aides familiar with the negotiations. Experts have been working to craft a number of policy options that lawmakers can mix-and-match to create a final policy outline.

Senate Budget rules allow GOP leaders to scrap nearly every element of the health legislation that passed the House. The only requirement is that the Senate save $133billion, the same amount saved in the House bill.

Republicans are trying to pass a health-care bill through a procedural maneuver known as reconciliation that only requires a simple majority rather than a supermajority. But for McConnell, getting to 50 votes (Vice President Pence could break a 50-50 tie) means losing no more than two Republican senators.

Complicating matters further, leaders must also jump through a series of other procedural hoops, like waiting for an official cost estimate before the health-care bill can come up for a vote. That process typically takes around two weeks, meaning leaders would need to have a final bill in hand soon to get it scored and hold a vote by the end of next month.

Some Republican leaders sound much more like they are wishing that will happen than are counting on it.

I dont think this gets better over time, said Senate Republican Conference Vice Chairman Roy Blunt (Mo.). So my personal view is weve got, you know, about until now until the Fourth of July to decide whether the votes are there are not. And I hope they are.

Paul Kane contributed to this report.

Continued here:

Senate GOP aiming to conclude divisive health-care push one way or the other - Washington Post

TechCrunch

The consumerization of healthcare | TechCrunch TechCrunch Recently, I registered with the GP across the road from my flat. I've lived there for a year. I had put off registering beforehand due to a severe allergy.. and more »

Go here to see the original:

The consumerization of healthcare | TechCrunch - TechCrunch

Dont delude yourself that legislation to create a California universal healthcare system passed the state Senate last week. All that passed was authorization to keep yakking about it in dreamland.

Or you can look at it this way: A fantasy-driven single-payer healthcare concept was given the equivalent of a grade-school social promotion. It should have been held back for a lot more work but was advanced undeservedly to the next level.

The goal of the bill, SB 562, is to establish a state-run healthcare system that covers all 40 million Californians, including roughly 2 million who migrated here illegally.

There really arent any details, but as envisioned, it would replace all private and government insurance, including senior citizens Medicare. Right there, the bills advocates should stop. Federal Medicare works fine. Leave it alone.

The California concept is promoted as Medicare for all, except it wouldnt be Medicare. And it wouldnt include Medicares ability to buy extra service through a private plan.

No one can be sure of anything, however, because this is a hollow bill a bill in name only.

The legislative authors, Sens. Ricardo Lara (D-Bell Gardens) and Toni Atkins (D-San Diego), promised to keep trying to mold a real bill.

No one even knows the bills price tag. But whatever it is, its astronomical.

An analysis by the Senate Appropriations Committee, chaired by Lara, pegged it at $400 billion annually. To put that in perspective, total state spending for the next fiscal year is projected to be $290 billion, including $107 billion in federal dollars.

Lara says Californians currently spend $367 billion each year on healthcare federal, state and private money. His bill would use that money, eliminating private insurance. Thered be no patient co-pays or deductibles.

The California Nurses Assn., the bills loudest advocate, paid for a University of Massachusetts Amherst study that picked a $331-billion cost. Lara is running for state insurance commissioner with the nurses backing.

Even if the state gobbled up all the government and private money being spent on healthcare in California, thered still be a need for a state tax increase of up to $100 billion. A 15% payroll tax is envisioned. The nurses also suggested business and sales tax hikes. Lots of luck with that.

The rationale for passing a shallow bill devoid of substance was that June 2 was the deadline for a measure to be approved by its original house.

The way the rules work in the Legislature, we are deadline-driven, Sen. Bob Hertzberg (D-Van Nuys) argued during the long floor debate. The bill certainly has many holes, he said, but it should be kept alive and moved to the Assembly for negotiation and fine-tuning.

Except, the deadline argument was a poor excuse for the Senate not doing its job. Most legislative deadlines, like this one, are of the Legislatures own making. And the deadline can be suspended on a two-thirds vote the same vote that would be required to pass a substantive bill with a funding plan.

There would be a hard deadline Jan. 31 for Senate passage. But even after that, the proposals substance could be amended into legislation with a different bill number a common gut and amend tactic.

Updates from Sacramento

So what the Senate did was disappointing and rather shameful if youre a single-payer advocate. Rather than digging in and developing an actual plan, it passed the chore over to the Assembly, which hasnt shown much interest in the subject.

This is the most difficult issue Ive ever agreed to work on, Atkins told the Senate. Let me assure you Im serious about it. This is the biggest issue the state of California has undertaken in a very long time.

Then youd think it would have warranted more time and energy. But, realistically, its probably an impossible task given the complexity, competing interests and politics.

The bill passed on largely a party-line vote, 23 to 14, with most Democrats for it and all Republicans against. Because it didnt include any funding, only a simple majority vote was required.

Give four Democrats credit for refusing to support it: Sens. Steve Glazer of Orinda, Ben Hueso of San Diego, Richard Roth of Riverside and Richard Pan of Sacramento. Glazer voted no. The others abstained.

We should keep it here and finish the work, Glazer said, then put it on the ballot in 2018.

This is the Senate kicking the can down the road to the Assembly and asking the Assembly to fill in all of the blanks, Hueso said. I dont see this bill coming back from the Assembly. I think this bill will die in the Assembly.

Republicans brought up some practical problems for the bill. Start with the fact that California is only a state, not a nation. It would be almost impossible for one state to enact a single-payer system by itself.

And Californias anti-Trump Democratic legislators would need the Republican president to generously turn over federal Medicaid and Medicare funds to make their single-payer dream come alive.

We give Trump crap day in and day out, and were going to beg him for a couple hundred billion dollars? Sen. Tom Berryhill (R-Modesto) asked.

Anyway, even if the Legislature did manage to pass a bill, Gov. Jerry Brown probably would veto it. Hes very skeptical about the financing.

Well be watching what the Assembly produces. Maybe theyll surprise us. But probably therell just be more yak.

george.skelton@latimes.com

Follow @LATimesSkelton on Twitter

ALSO

Republicans are mad about the California gas tax, and they're taking it out on this freshman lawmaker

Excerpt from:

California state senators passed a single-payer healthcare bill, but it's going nowhere fast - Los Angeles Times

New York Times

From Maine, a Call for a More Measured Take on Health Care - The ... New York Times Susan Collins, attuned to the particular vulnerabilities of her constituents, is among a handful of senators thinking about repairing, not replacing, the health law. and more »

Read more:

From Maine, a Call for a More Measured Take on Health Care - The ... - New York Times

As an employer and a health care provider I would like to discuss several things that are not being addressed in the debate between Obamacare and Trumpcare.

Firstly, though it is a dirty little secret, between 40 percent and 50 percent of the population in the U.S. is already on government-funded health care and mostly they are happy with it.

If you add up all the employees of the military and their families, those eligible for VA health care, Medicare, Medicaid, federal, state, county and city employees and their families, individuals in prison, companies that depend mostly on government-funded projects like highway construction companies and defense companies, and heath care providers treating mostly Medicare patients and the disabled, you have a large part of the population on government-funded health care.

Secondly, what both parties are trying to do in addressing only health insurance is like rearranging the deck chairs on the Titanic. The reason health insurance costs are so high is due to what it insures, health care. The cost of health care is high and getting more so. Neither party is addressing this. It is as if everyone drives a Rolls Royce and we are wondering why car insurance costs so much. As an employer, I saw the same double-digit increases to health insurance premiums before Obamacare as I do now afterward.

I have heard a lot of nonsense about allowing the free market to work here. Health care in the U.S. does not function on a free market basis. There is no way to choose one hospital over another as to quality and cost. When you go into an emergency room you have no idea what your costs will be. You just walk out of the hospital afterward and hope you can pay your share. Anyone who has ever examined a hospital bill will tell you it is beyond understanding.

Allowing health insurance providers to sell stripped-down plans is the same as just increasing the deductible. It just allows the insurers to call it a non-covered procedure rather than tacking the charges on the deductible. Health care is a necessity. No one goes through their whole life and refuses to ever see a doctor. The federal government acknowledges this by requiring hospitals to treat anyone who walks into an emergency room whether they can pay or not. If health care was free market, hospitals could tell people "sorry you don't have insurance, so go die."

My proposal to both parties is to provide a federal re-insurance for the health insurance providers. Let's say an individual has more than $100,000 in a year in health insurance costs, then a type of Trumpcare along the lines of Medicare would step in and take over the costs. In addition, if an individual has more than $1 million in health insurance costs over their lifetime, what the old lifetime maximum was, then they would become instantly eligible for Medicare. Medicare is essentially a high-risk group insurance anyway and most people who need that much health care will end up disabled and soon on Medicare.

By limiting the losses to the insurers it should help to keep costs down. The costs of the program will only go to those we know are high risk and not individuals that insurers would perceive to be high risk. Medicare also approaches the costs of health care differently than most insurers by paying for the disease and not just procedures and supplies used. This is a real attempt to control costs. Medicare also has much lower administrative costs than private insurance.

Once we have addressed the costs of health insurance we need to take a good look at the cost of heath care. The answers to that puzzle are more complicated and require wiser men than me.

In addition, we should not switch regular Medicaid to block grants to the states. As most welfare payments go to support people in nursing homes and with us baby boomers reaching that age, going to block grants will put an incredible strain on state budgets. Remember Sens. John Hoeven, R-N.D., and Heidi Heitkamp, D-N.D., you were all once state officials and what it takes to balance a state budget.

Could Congress also reduce the reporting paperwork of Obamacare and simplify it? One of our office managers spent three full days this year just filling out the Obamacare forms that no one will ever look at. It was ridiculous.

Bradley King is a lifelong resident of Bismarck and founder and senior partner at Prairie Rose Family Dentists in Bismarck and Mandan.

Go here to see the original:

What's not discussed in health care - Bismarck Tribune

New York Times

Rebuking Congress, Cuomo Plans to Keep State Health Care Plans Intact New York Times The measures, taken via emergency regulations, will include requiring any private company doing business on the state's insurance marketplace to guarantee the 10 essential health benefits required by President Barack Obama's signature 2010 health ...

Go here to read the rest:

Rebuking Congress, Cuomo Plans to Keep State Health Care Plans Intact - New York Times

Wall Street Journal (subscription)

Health Care in Iowa Shows Peril for Both Political Parties Wall Street Journal (subscription) Chuck Grassley's town-hall meeting to press the Republican senator on the GOP plan to overhaul health care. Mr. Barnum has health insurance through his work. But his family depends on Medicaid to help cover the medical costs of his 9-year-old son, Koan ... and more »

Read more:

Health Care in Iowa Shows Peril for Both Political Parties - Wall Street Journal (subscription)

Republican Sen. Ron Johnson believes it would be easier for the Senate to focus on tax reform instead of healthcare.

The Wisconsin senator is the latest lawmaker to cast doubt on the prospects for getting Obamacare repeal done in the Senate quickly.

"I think tax reform is an easier lift," he told the radio station AM 970 The Answer. "There are a number of pretty good proposals out there."

Johnson speculated that getting Obamacare passed is going to be harder than it looks. Johnson has been pushing for a short-term bill to stabilize Obamacare's exchanges while working on long-term reform.

"We may have to break this into two pieces," he said.

He said the Senate should take its time to put together a healthcare bill that "restrains the cost of healthcare."

Senate committee and leadership staff is putting together legislative text that outlines the ideas being bandied about by a group of more than a dozen senators.

But the text is expected to be just a draft and reference point for continuing negotiations. Major rifts in the GOP conference remain over Medicaid spending and how generous tax credits should be.

Johnson isn't the only senator to vocalize his skepticism on whether a deal gets done on healthcare soon.

Sen. Richard Burr, R-N.C., recently said he also doubts that healthcare gets done this year at all.

More:

Ron Johnson: Tax reform an easier lift than healthcare - Washington Examiner

A West Michigan doctor wishes to trade in his scrubs for a seat in Congress.

Jaleesa Irizarry, WZZM 11:19 PM. EDT June 04, 2017

U.S. Rep. Bill Huizenga has an early challenger in the 2018 election:Rob Davidson, an ER doctor who challenged the congressman on health care at an earlier town hall event.

GRAND HAVEN, MICH. - A West Michigan emergency room doctor who squared off with a congressman at an earlier town hall event says he's ready to challenge him for his seat.

Rob Davidson has worked in an ER for 16 years but he says after this November election, he needed to stand up for his beliefs. He's already is raising money as a Democratic candidate against U.S. Rep. Bill Huizenga, R-Zeeland.

WZZM 13 first interviewed Davidson in February at a Huizengatown hall event in Baldwin, Mich.

"My concern is 10-15 years from now, these people have heart attacks and strokes that perhaps could have been prevented if they had the access that they needed," he said minutes before the town hall.The West Michigan man debated with the Republican congressman during that event.

"I had a question and we had a little mini debate on health care and a lot of people just spontaneously started asking me, 'Why don't you run?'"After that day, Davidson started strongly considering it. A few months ago, he decided to turn his fight for health care into a campaign to challengeHuizenga in the 2018 congressional election.

"I see a lack of fairness and the ability for people to get health care," Davidson said Sunday, June 4, at a healthcare rally.At that February town hall,Huizenga said there some good things about the Affordable Care Act, but it needed to be repealed.

"I have made a commitment to things like pre-existing conditions should not be a disqualifier, a lifetime cap should not be a disqualifier, a number of other things that we think are positives in that and we're going to try and make sure those are in there," Huizenga said in February.

"It just has to be a system where those of us who consume healthcare, as patients, have more understanding of the true costs and have more input as to what our decisions are."

Huizenga voted for that repeal in May showing support for the GOP health care bill, saying, in part,in a press release: "...The American Health Care Act provides the relief countless families across West Michigan have been asking for..."

"The American Healthcare Act was really a tax-cut for the wealthiest disguised as a healthcare bill and they paid for it by kicking 24 million people off of Medicaid," Davidson said.

Besides health care, Davidson hopes to advocate for education as well. He says he plants to hold events for his campaign in the future.

We reached out to Huizenga's campaign for a response to the news of a challenger.

They sent WZZM 13 the following statement: "Bill was reelected by a two to one margin just 8 months ago. For now he's focused on policies to create jobs, protect life, and serve the constituents of the 2nd District.

"While it's no surprise a liberal candidate has announced, Bill has a job to do to and is focused on making West Michigan an even better place to live, work, and raise a family."

Makeit easy to keep up to date with more stories like this.Download theWZZM13 app now.

Have a news tip? Emailnews@wzzm13.com, visit ourFacebookpage orTwitter.

2017 WZZM-TV

Follow this link:

After health care debate, ER doctor runs against US Rep. Bill Huizenga - WZZM

On Thursday, a panel of health, business and advocacy leaders gathered in Lancaster for a public town hall on health care.

The event covered a wide range of topics within health care.

Here are three key questions that arose.

Would Medicare for more be better?

Dr. David Silbert, a local ophthalmologist, told panelists Medicare seems to be effectively controlling medical costs, and he thinks expanding the program could be helpful.

If Medicaid pays 30 cents on the dollar, she said, everyone ends up paying the remaining 70 cents, because that cost gets distributed for other people that are paying for health insurance and buying health care services.

Chuck Pennacchio, executive director of Healthcare For All PA, said Medicare having much lower administrative costs than other payers makes a good argument for expanding it.

Akash Chougule, deputy director of policy of Americans for Prosperity, said government underwriting things automatically makes them more expensive.

Can people make good enough health care choices?

One audience member questioned whether its possible for individual choice to result in good overall outcomes for Americas health care, given the complexity of the issues.

Another person from the audience said as she has seen more and more people left behind by the choice model, she has begun to view health care as a moral challenge confronting America.

Do we need to do better on health insurance literacy and understanding? Absolutely, said Paula Bussard, chief strategy officer of the Hospital & Healthsystem Association of Pennsylvania.

But, she said, the industry also has to do more to empower patients.

Marc Stier, director of the Pennsylvania Budget and Policy Center, said America collectively pays for health care, including the tax deduction that benefits everyone who has job-based health insurance, and thats an argument for universal health care.

Would more local control be better?

Asked what they liked about the recent American Health Care Act proposal, the panel had little to say.

Lifting taxes was a positive, said Gene Barr, president & CEO of Pennsylvania Chamber of Business and Industry. Taking coverage away from people was problematic.

Bergen said while shes wary of the impact of block-granting Medicaid, the effort to try to drive decision-making, control, etc. at the state and a more localized level could have some very tremendous benefits that should be fully considered.

Pennsylvania Auditor General Eugene DePasquale, who organized the event with Treasurer Joe Torsella, asked later about regulations.

How do we get to a place politically where we actually go through the regulatory process to see what works and what doesnt? he said.

Barr said he sees a need to frame the conversation in terms of tradeoffs, instead of good and bad.

With economic regulation, theres almost always going to be a drag on economic development, he said. Am I willing to accept additional protection for a little less economic development?

See the original post here:

3 key questions from the health care town hall in Lancaster County - LancasterOnline