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Learning To Care For My Newborn Was A Humbling Experience

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With motherhood comes new challenges.

Maria Fabrizio for NPR

Wen is an emergency physician and the health commissioner of Baltimore City.

Two months ago, my husband and I welcomed our baby son, Eli, into the world. Hearing his first cry and getting to hold him were the happiest moments of our lives. When he was placed on my chest and I could see and touch him, I felt like I knew him already. The doctors told us he was healthy and well. I couldn’t wait to start our lives together as a family.

The night we arrived home, Eli wouldn’t stop crying. Crying is normal in newborns, my husband and I assured each other. We held him and rocked him. Over the next 48 hours, we took shifts, staying up with Eli to try to soothe him through the near-nonstop crying. We called our friends for advice on how to deal with what we now labeled a “difficult baby.”

Things went downhill quickly. Our pediatrician confirmed that he was noticeably jaundiced. In just three days, he had lost 15 percent of his body weight. Though I was feeding him every two hours, it turned out that Eli never had a good latch on my breasts, and I wasn’t producing enough milk. We were told that he might need to be readmitted to the hospital.

I was overcome with shame and guilt. What kind of mother am I who was barely keeping my own baby alive? What is wrong with my body that something so natural didn’t happen? How could I, as a physician, not recognize that my baby was actually starving — and instead, blame him for expressing hunger in the only way he was able to?

As Eli began to catch up on feeds, I tried to gain perspective. Becoming a mother brings many new challenges. No matter how much I may know about the scientific benefits of breast-feeding, I needed help. My hospital has a wonderful lactation consultant and I have a terrific pediatrician; together, they helped us to get back on track. As I learned, I was hardly alone; 92 percent of women have trouble with breast-feeding initially. This was one of many humbling realizations that caring for a newborn requires many skills that I had yet to learn.

My experience has made me even more dedicated to public health programs to support women and ensure a healthy start for their babies. I’m health commissioner for the city of Baltimore, and responsible for overseeing programs like the B’More for Healthy Babies (BHB) initiative, which provides home visits by nurses, social workers and community health aides. They teach parents the ABCs of safe sleep (Alone, on the Back, in a Crib) and help with breast-feeding, resources to quit smoking, and other services like assistance with housing.

Since BHB started in 2009, the city has cut infant mortality by nearly 40 percent and reduced the disparity between African-American and white mortality by half. BHB’s engagement with every Baltimore hospital and dozens of community groups and churches has resulted in a 70 percent reduction in sleep-related infant deaths in just seven years.

The program also works to improve on women’s health before and during pregnancy. Studies show that women who do not receive prenatal care are five times more likely to have babies who die than women who do. I was fortunate that I received excellent care from a terrific obstetrician at Mercy Hospital. I was also fortunate that I have good health insurance. When complications occurred that necessitated additional ultrasounds and blood tests, I didn’t hesitate to do what was best for my baby. Not all women are that lucky. We must do everything we can to safeguard programs like Medicaid so that women who face economic and social challenges have the opportunity to raise healthy children.

Furthermore, the United States remains only one of two countries in the world that does not have paid parental leave. Despite ample research showing health benefits for maternity leave, including fewer illnesses in babies and reduced maternal depression, up to 1 in 4 women are back to work within two weeks of giving birth. I had an uncomplicated delivery and am otherwise healthy, but I cannot fathom being back at work when my baby required near-constant attention and my body was still healing. Going back to work after eight weeks has been a challenge, and that’s with a caring partner, reliable child care and a supportive workplace.

If the health of families and future of children are core values in our society, then we should implement policies that foster these values. We need health care for all regardless of ability to pay; paid parental and sick leave; and affordable child care. We must recognize that caring for newborns is hard, and that women and families need support and services to give every child the chance to grow and to thrive. We must uphold our duty to care for the most vulnerable and level the playing field of inequality.

This week, hundreds of families will gather at the National Aquarium to celebrate BHB’s anniversary. As I prepare remarks to share there with the families that I serve, I also celebrate Eli’s two-month “birthday” with a visit to the pediatrician. I am thrilled that he has more than made up for the initial weight loss and is now a happy and chubby 11-pounder. He also received his immunizations at this visit, which gives me the perfect opportunity to add an important public health message: vaccines are safe, effective, and life-saving!

There is much that I have yet to learn about motherhood and caring for my baby, but I feel so blessed every day to have him and to embark on the next chapter of our journey together.

Dr. Leana Wen is the author of When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care. And she’s on Twitter: @DrLeanaWen

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Many Breast Cancer Patients Receive More Radiation Therapy Than Needed

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Annie Dennison said doctors offered just one option after her breast cancer diagnosis last year: six weeks of radiation treatment.

Courtesy of Annie Dennison

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Courtesy of Annie Dennison

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

“You’re terrified out of your mind” after a diagnosis of cancer, said Dennison, 55, a retired psychologist from Orange County, Calif.

In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 – six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.

In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison – who was over 50, with a small cancer that hadn’t spread – without considering the shorter therapy.

“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”

Dennison’s oncologist, Dr. David Khan of El Segundo, Calif., notes that there are good reasons to prescribe a longer course of radiation for some women.

Khan, an assistant clinical professor at UCLA, said he was worried that the shorter course of radiation would increase the risk of side effects, given that Dennison had undergone chemotherapy as part of her breast cancer treatment. The latest radiation guidelines, issued in 2011, don’t include patients who’ve had chemo.

Yet many patients still aren’t told about their choices.

An exclusive analysis for Kaiser Health News found that only 48 percent of eligible breast cancer patients today get the shorter regimen, in spite of the additional costs and inconvenience of the longer type.

The analysis was completed by eviCore healthcare, a South Carolina-based medical benefit management company, which analyzed records of 4,225 breast cancer patients treated in the first half of 2017. The women were covered by several commercial insurers. All were over age 50 with early-stage disease.

The data “reflect how hard it is to change practice,” said Dr. Justin Bekelman, associate professor of radiation oncology at the University of Pennsylvania Perelman School of Medicine.

A growing number of patients and doctors are concerned about overtreatment, which is rampant across the health care system, argues Dr. Martin Makary, a professor of surgery and health policy at the Johns Hopkins University School of Medicine in Baltimore.

From duplicate blood tests to unnecessary knee replacements, millions of patients are being bombarded with screenings, scans and treatments that offer little or no benefit, Makary said. Doctors estimated that 21 percent of medical care is unnecessary, according to a survey Makary published in September in the journal PLOS One.

Unnecessary medical services cost the health care system at least $210 billion a year, according to a 2009 report by the National Academy of Medicine, a prestigious science advisory group.

Those procedures aren’t only expensive. Some clearly harm patients.

Overzealous screening for cancers of the thyroid, prostate, breast and skin, for example, leads many older people to undergo treatments unlikely to extend their lives, but which can cause needless pain and suffering, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice.

“It’s just bad care,” said Dr. Rebecca Smith-Bindman, a professor at the University of California-San Francisco, whose research has highlighted the risk of radiation from unnecessary CT scans and other imaging.

Outdated Treatments

All eligible breast cancer patients should be offered a shorter course of radiation, said Dr. Benjamin Smith, an associate professor of radiation oncology at the University of Texas MD Anderson Cancer Center.

Studies show that side effects from the shorter regimen are the same or even milder than traditional therapy, Smith said.

“Any center that offers antiquated, longer courses of radiation can offer these shorter courses,” said Smith, lead author of the radiation oncology society’s 2011 guidelines.

Smith, who is currently updating the expert guidelines, recently said there’s no evidence that women who’ve had chemo have more side effects if they undergo the condensed radiation course.

“There is no evidence in the literature to suggest that patients who receive chemotherapy will have a better outcome if they receive six weeks of radiation,” Smith said.

Shorter courses save money, too. Bekelman’s 2014 study in JAMA, the journal of the American Medical Association, found that women given the longer regimen faced nearly $2,900 more in medical costs in the year after diagnosis.

The high rate of overtreatment in breast cancer is “shocking and appalling and unacceptable,” said Karuna Jaggar, executive director of Breast Cancer Action, a San Francisco-based advocacy group. “It’s an example of how our profit-driven health system puts financial interests above women’s health and well-being.”

Just getting to the hospital for treatment imposes a burden on many women, especially those in rural areas, Jaggar said. Rural breast cancer patients are more likely than urban women to choose a mastectomy, which removes the entire breast but typically doesn’t require follow-up radiation.

Too Many Tests

Meg Reeves, 60, believes much of her treatment for early breast cancer in 2009 was unnecessary. Looking back, she feels like she was treated “with a sledgehammer.”

Meg Reeves believes that much of the treatment she received after being diagnosed with breast cancer was unnecessary.

Courtesy of Meg Reeves

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Courtesy of Meg Reeves

At the time, Reeves lived in a small town in Wisconsin and had to travel 30 miles each way for radiation therapy. After she completed her course of treatment, doctors monitored her for eight years with a battery of annual blood tests and MRIs. The blood tests include screenings for tumor markers, which aim to detect relapses before they cause symptoms.

Yet cancer specialists have repeatedly rejected these kinds of expensive blood tests and advanced imaging since 1997.

For survivors of early breast cancer like Reeves – who had no signs of symptoms of relapse — “these tests aren’t helpful and can be hurtful,” said Dr. Gary Lyman, a breast cancer oncologist and health economist at the Fred Hutchinson Cancer Research Center. Reeves’ primary doctor declined to comment.

In 2012, the American Society for Clinical Oncology, the leading medical group for cancer specialists, explicitly told doctors not to order the tumor marker tests and advanced imaging — such as CT, PET and bone scans — for survivors of early-stage breast cancer.

Yet these tests remain common.

Thirty-seven percent of breast cancer survivors underwent screening for tumor markers between 2007 and 2015, according to a study presented in June at the American Society of Clinical Oncology’s annual meeting and published in the society’s journal online.

Sixteen percent of these survivors underwent advanced imaging. None of these women had symptoms of a recurrence, such as a breast lump, Lyman said.

Beyond wasted time and worry for women, these scans also expose them to unnecessary radiation, a known carcinogen, Lyman said. A National Cancer Institute study estimated that 2 percent of all cancers in the United States could be caused by medical imaging.

Paying The Price

Health care costs for breast cancer patients monitored with advanced imaging averaged nearly $30,000 in the year after treatment ended. That was about $11,600 more than for women who didn’t get such follow-up tests, according to Lyman’s study. Women monitored with biomarkers had nearly $6,000 in additional health costs.

Reeves knows the costs of cancer treatment all too well. Although she had health insurance from her employer, she says she had to sell her house to pay her medical bills. “It was financially devastating,” Reeves said.

“It’s the worst kind of financial toxicity, because you’re incurring costs for something with no benefit,” said Dr. Scott Ramsey, director of the Hutchinson Institute for Cancer Outcomes Research.

Even simple blood tests take a toll, Reeves said.

Repeated needle sticks – including those from unnecessary annual blood tests — have scarred the veins in her left arm, the only one from which nurses can draw blood, she says. Nurses avoid drawing blood on her right side – the side of her breast surgery – because it could injure that arm, increasing the risk of a complication called lymphedema, which causes painful arm swelling.

Reeves also worries about the side effects of so many scans.

After treatment ended, her doctor also screened her with yearly MRI scans using a dye called gadolinium. The Food and Drug Administration is investigating the safety of the dye, which leaves metal deposits in organs such as the brain. After suffering so much during cancer treatment, she doesn’t want any more bad news about her health.

Becoming An Advocate

Kathi Kolb, 63, was staring at 35 radiation treatments over seven weeks in 2008 for her early breast cancer. But she was determined to educate herself and find another option.

“I had bills to pay, no trust fund, no partner with a big salary,” said Kolb, a physical therapist from South Kingstown, R.I. “I needed to get back to work as soon as I could.”

Kathi Kolb, a Rhode Island physical therapist, says she’s frustrated that fewer than half of eligible breast cancer patients receive a shorter course of radiation, even though studies proved it was safe nearly 10 years ago.

Katye Martens Brier for KHN

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Katye Martens Brier for KHN

Kolb asked her doctor about a 2008 Canadian study showing that three weeks of radiation was safe. He agreed to try it.

Even the short course left her with painful skin burns, blisters, swelling, respiratory infections and fatigue. She fears these symptoms would have been twice as bad if she had been subjected to the full seven weeks.

“I saved myself another month of torture and being out of work,” Kolb said. “By the time I started to feel the effects of being zapped [day] after day, I was almost done.”

A growing number of medical and consumers groups are working to educate patients, so they can become their own advocates.

The Choosing Wisely campaign, launched in 2012 by the American Board of Internal Medicine Foundation, aims to raise awareness about overtreatment. The effort, which has been joined by 80 medical societies, has listed 500 practices to avoid. It advises doctors not to provide more radiation for cancer than necessary, and to avoid screening for tumor markers after early breast cancer.

“Patients used to feel like ‘more is better,’ ” said Daniel Wolfson, executive vice president of the ABIM Foundation. “But sometimes less is more. Changing that mindset is a major victory.”

Yet Wolfson acknowledges that simply highlighting the problem isn’t enough.

Many doctors cling to outdated practices out of habit, said Dr. Bruce Landon, a professor of health care policy at Harvard Medical School.

“We tend in the health care system to be pretty slow in abandoning technology,” Landon said. “People say, ‘I’ve always treated it this way throughout my career. Why should I stop now?’ “

Many doctors say they feel pressured to order unnecessary tests out of fear of being sued for doing too little. Others say patients demand the services. In surveys, some doctors blame overtreatment on financial incentives that reward physicians and hospitals for doing more.

Because insurers pay doctors for each radiation session, for example, those who prescribe longer treatments earn more money, said Dr. Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes in New York.

“Reimbursement drives everything,” said economist Jean Mitchell, a professor at Georgetown University’s McCourt School of Public Policy. “It drives the whole health care system.”

Smith-Bindman, the UC-San Francisco professor, said the causes of overtreatment aren’t so simple. The use of expensive imaging tests also has increased in managed care organizations in which doctors don’t profit from ordering tests, her research shows.

“I don’t think it’s money,” Smith-Bindman said. “I think we have a really poor system in place to make sure people get care that they’re supposed to be getting. The system is broken in a whole lot of places.”

Dennison said she hopes to educate friends and others in the breast cancer community about new treatment options and encourage them to speak up. She said, “Patients need to be able to say, ‘I’d like to do it this way because it’s my body.’ “

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Rural Hospice That Spurns Federal Funds Has Offered Free Care for 40 Years

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Helping her father die at home “was the most meaningful experience in my nursing career,” said Rose Crumb. She went on to found Volunteer Hospice of Clallam County in Port Angeles, Wash.

Dan DeLong for Kaiser Health News

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Dan DeLong for Kaiser Health News

Rose Crumb can’t even count the number of people she’s helped die.

The former nurse, 91, who retired in her mid-80s, considers the question and then shakes her head, her blue eyes sharp above oval spectacles.

“Oh, hundreds,” estimates Crumb, the woman who almost single-handedly brought hospice care to the remote Pacific Northwest city of Port Angeles, Wash., nearly 40 years ago.

But the actual number of deaths she has witnessed is likely far higher — and Crumb’s impact far greater — than even she will admit, say those affiliated with the Volunteer Hospice of Clallam County.

“[Rose] let people know hospice is not all about dying,” said Bette Wood, who manages patient care for VHOCC. “Hospice is about how to live each and every day.”

In a nation where Medicare pays nearly $16 billion a year for hospice care, and nearly two-thirds of providers are for-profit businesses, the tiny volunteer hospice is an outlier.

Since 1978, the hospice founded by Crumb — a mother of 10 and devoted Catholic — has offered free end-of-life care to residents of Port Angeles and the surrounding area. She was the first in the region to care for dying AIDS patients in the early days of the epidemic. Her husband, “Red” Crumb, who died in 1984 of leukemia, was an early patient.

“He died the most perfect death,” Rose Crumb told visitors on a recent afternoon. “He spent time alone with each of our kids. That meant so much to him.”

At the same time, Crumb and her successors have refused to accept federal funding or private insurance, relying instead on a mostly volunteer staff and community donations to keep the hospice going.

That’s rare, said Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization, NHPCO, a trade group. Most of the nation’s 4,000-plus hospices receive Medicare payments for their services. He estimates there are only a few volunteer hospices like Crumb’s in the U.S.

There was pressure in the early years to “take the money,” as Crumb put it. But she had little use for the regulations that accompanied federal Medicare reimbursement starting in 1982.

“It was our experience that we could operate on a much smaller budget and we could be more flexible in providing services,” Crumb wrote in a 2007 newsletter.

Today, the hospice relies on 10 paid staff, 160 volunteers and an annual budget of less than $400,000 to provide end-of-life care for 300 patients each year, according to federal records.

Patients don’t have to meet Medicare’s criteria of having six months or less to live to be enrolled, though most do. They can keep their own doctors instead of turning over care to a hospice physician. If families need medical equipment, the hospice supplies it for free.

Eve Farrell holds a portrait of her husband, Daniel, in her Port Angeles, Wash., home. He died in January of chronic obstructive pulmonary disease.

Dan DeLong for Kaiser Health News

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Dan DeLong for Kaiser Health News

“I don’t know how I would have made it without them,” said Eve Farrell, 82, whose husband, Daniel, had cardiopulmonary obstructive disorder, or COPD. He died in January at age 80 after four months of hospice care at the couple’s Port Angeles home.

Staffers helped her husband shower when she couldn’t lift him, offered advice about medication and gave her breaks from relentless caregiving.

“We felt like Dan was the only patient they had,” Eve Farrell said.

Crumb was drawn to hospice care in the 1970s, after the book “On Death and Dying” by Dr. Elisabeth Kübler-Ross galvanized conversations in the U.S. about how to treat the terminally ill. Years earlier, when Crumb’s father was diagnosed with lymphoma, she helped him die at home.

“It was the most meaningful experience in my nursing career,” she said.

In April 1977, when Crumb attended a convention that included a program on hospice, she was hooked.

“Everything clicked,” she recalled. “I thought ‘Yes!’ “

Organizers had little money and less support, Crumb said. The local medical community was skeptical about hospice, which started in the U.S. in Connecticut in 1974.

“Some of the doctors called us ‘the death squad,'” Crumb said. Crumb’s refusal to take federal funds put her at odds with the for-profit hospice industry, which lobbied state lawmakers in 1992 to eliminate an exemption that allowed volunteer hospices to remain unlicensed.

Crumb had to enlist the services of her eighth child, Patrick Crumb, then a corporate lawyer, to fight back.

“In my view, they were clearly misrepresenting the current status of the law,” recalled Patrick Crumb, 55, who is now president of the AT&T Sports Network. “I told them, ‘If you do what you’re threatening to do, I’m going to sue you and I’m going to win.’ “

Lawmakers eventually agreed to create an exemption to state law that allows volunteer hospices to remain unlicensed and unregulated. Crumb’s hospice remains the only agency in state history to use it.

In 2002, the volunteer hospice faced a for-profit rival, Assured Home Health and Hospice, now owned by the LHC Group based in Lafayette, La. Documents show that Assured officials predicted they’d serve 70 percent of the local hospice market within two years.

Since 1978, the Volunteer Hospice of Clallam County has offered free end-of-life care to residents of Port Angeles, Wash.

Dan DeLong for Kaiser Health News

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Dan DeLong for Kaiser Health News

But competition was fierce, recalled Dr. Tom Kummet, medical director at the Olympic Medical Cancer Center, who referred dying patients to hospice care.

“It was a bit of an awkward time,” he said. “Assured hospice wanted to be a successful business. And Volunteer Hospice was going to negatively impact their chances of being a successful business.”

Fifteen years later, Assured still struggles, said Leslie Emerick, director of public policy and outreach for the Washington State Hospice and Palliative Care Organization.

“They tread lightly up there because of Rose,” Emerick said. “Rose is a beloved person in that community.”

Officials with LHC declined to discuss competition in the Port Angeles market or to say how many patients Assured has enrolled.

“We value the care that Volunteer Hospice provides for our community,” Candace Hammer Chaney, a local Assured manager and community liaison, said in a statement.

Emerick and other hospice industry officials said volunteer hospices don’t offer the range of services required of those who receive federal funding. And, Emerick added, there’s little oversight.

“They don’t have a reputation of negligence or complaints as far as I’m aware, but there’s always the possibility of that when they’re unlicensed or unregulated,” she said.

But Astrid Raffinpeyloz, VHOCC’s volunteer services manager, said the hospice wouldn’t have lasted long in a small town if there were problems.

“We don’t have oversight from the government, but we have minute oversight from the community,” said Raffinpeyloz.

Mike Clapshaw poses with a picture of him and his wife, Deborah, in his Port Angeles, Wash., home.

Dan DeLong for Kaiser Health News

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Dan DeLong for Kaiser Health News

For Mike Clapshaw, 71, there was no question about who would care for his wife, Deborah, when her cancer came back for the third time, leading to her death in December 2014. She was 60. For the last four months of her life, VHOCC staff eased her pain — and his.

“It was always, ‘What can I do to help?’ ” he said.

Helping was always the point, said Rose Crumb, whether the pain at the end of life was physical, emotional — or both.

“Some people just need someone to listen to them,” she said.

Crumb at nearly 92, now suffers from osteoporosis, congestive heart failure and other ailments that plagued her patients in earlier years. But she’s not worried about her final days.

“I’m all signed up for hospice,” she said. “I have everything written down.”

KHN’s coverage of end-of-life and serious illness issues is supported byThe Gordon and Betty Moore Foundation.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Sure, There's A Health Care Deal. That Doesn't Mean It Can Pass

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Sen. Lamar Alexander, R-Tenn., chairman of the Senate Health, Education, Labor, and Pensions Committee, talks to reporters on Capitol Hill Wednesday.

Carolyn Kaster/AP

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Carolyn Kaster/AP

Updated at 3:55 p.m. ET

A bipartisan coalition of 24 senators — 12 Republicans and 12 Democrats — has signed on to health care legislation to prop up the individual insurance market and keep premiums down. With the expected support of all Senate Democrats, it could have the votes to pass the chamber. But questions remain over when it might actually get a vote, as well as whether President Trump and House Republicans would bring the bill over the finish line.

“This is a first step: Improve it, and pass it sooner rather than later. Our purpose is to stabilize and then lower the cost of premiums in the individual insurance market for the year 2018 and 2019,” said Sen. Lamar Alexander, R-Tenn., on the Senate floor. Alexander and Sen. Patty Murray, D-Wash., crafted the compromise bill.

Alexander and Murray have been working on this legislation for months. Negotiations initially began after the Senate failed to pass legislation to repeal and replace Obamacare back in July.

Most Americans get health insurance through their employer or from the government. About 18 million Americans get their insurance through the individual market established by the Affordable Care Act. “They’re the ones we’re worried about; they’re the ones we’re seeking to help,” Alexander said, noting that includes about 350,000 people in his home state.

“I have to say that after seven years of intense partisanship on these issues, which would lead everyone to believe there was no hope for Republicans and Democrats to come together and work to strengthen our health care, I’m really pleased with this common ground we’ve been able to find,” Murray said on the Senate floor.

President Trump’s decision last week to end subsidies to insurance companies that were allowed under the ACA revived congressional talks. The Trump administration argued — and initial court rulings backed it up — that the payments were illegal because they had not been appropriated by Congress, which has the constitutional authority to spend the government’s money. Although the 2010 health care law required insurers to provide discounts to some low-income consumers and said the government would reimburse them, without authorizing the spending.

The Alexander-Murray proposal would appropriate those subsidies for two years, and tie them to permanent changes to the law that give states more flexibility to seek waivers from the Health and Human Services Department from the ACA’s requirements. It would also allow insurances companies to sell less comprehensive plans to all customers, not just those under age 29 as is the case under current law.

The nonpartisan Congressional Budget Office estimates that without the subsidies, premiums will go up, the deficit will rise and up to 16 million Americans could live in counties with no insurance providers at all.

“Unless they are replaced with something else temporarily, there will be chaos in this country and millions of Americans will be hurt,” Alexander warned.

Alexander said Trump has been privately encouraging of the talks, but the president cast doubts on the legislation this week by suggesting it was a “bailout” for insurance companies that he could not support. However, the bill’s sponsors counter that the legislation requires that the subsidies go directly to the consumer to keep premiums down.

The bipartisan bill has potentially critical GOP support from Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona. The trio played a defining role in the defeat of previous GOP health care bills this year. It also has the backing of Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, who have competing legislation to dismantle the ACA and replace it with a block grant system to the states.

GOP backers say the bill does not pre-empt the party’s ongoing effort to end Obamacare but rather buys time to keep working on legislation that can muster enough support to pass Congress. Conservatives have balked at Alexander-Murray as a tacit admission that Obamacare will remain the law of the land. House Speaker Paul Ryan said through a spokesman Wednesday that the speaker believes the Senate should remain focused on legislation to end Obamacare, not prop it up.

The proposal puts the GOP in a bind between the policy necessity to act to protect millions of Americans from premium hikes and the political necessity to continue to keep up its effort to dismantle the current system. An August poll from the Kaiser Family Foundation found that 60 percent of Americans think Trump and Republicans in Congress are responsible for what happens to the ACA in the future.

Senate Majority Leader Mitch McConnell has not taken a position on the bill, but he is unlikely to bring something to the floor unless it has Trump’s support and the 60 votes needed to clear a potential filibuster, which it should if all 48 Senate Democrats support it along with the 12 Republicans who have signed on. The legislation crowds an already limited legislative calendar. It would need to become law before the end of the year when Congress needs to pass a spending bill package to keep the government running. That spending bill would be the vehicle to fund the insurance subsidies.

Along with Alexander, Collins, Murkowski, McCain, Graham and Cassidy, the additional GOP co-sponsors include Sens. Mike Rounds of South Dakota, Joni Ernst and Chuck Grassley of Iowa, Bob Corker of Tennessee, Richard Burr of North Carolina and Johnny Isakson of Georgia.

The Democratic co-sponsors joining Murray include Sens. Angus King, independent of Maine, Jeanne Shaheen and Maggie Hassan of New Hampshire, Joe Donnelly of Indiana, Amy Klobuchar and Al Franken of Minnesota, Heidi Heitkamp of North Dakota, Joe Manchin of West Virginia, Tom Carper of Delaware, Tammy Baldwin of Wisconsin and Claire McCaskill of Missouri.

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