Health Care Reform Articles - August 12, 2015

Medicare, Reversing Itself, Will Pay More for an Expensive New Cancer Drug

By ROBERT PEARAUG. 8, 2015

WASHINGTON — The Obama administration has decided that Medicare will pay for one of the newest, most expensive cancer medications, which costs about $178,000 for a standard course of treatment.

Patients, doctors, hospital executives and insurers have expressed concern about the high cost of prescription drugs, especially new cancer medicines and treatments tailored to the genetic characteristics of individual patients. Medicare officials recognized the cost and value of one such product, the anticancer drug Blincyto, by agreeing to make additional payments for it starting Oct. 1. The drug is made by Amgen for patients with a particularly aggressive form of leukemia.

The decision suggests a new willingness by Medicare to help pay for promising therapies that are still being evaluated. It is also significant because Medicare officials reversed themselves on every major scientific issue involved. After receiving pleas from Amgen and a dossier of scientific evidence, the officials agreed that the drug was a substantial improvement over existing treatments for some patients.

At issue are special “add-on payments” that Medicare makes to hospitals for new technology whose costs are not yet reflected in the standard lump-sum amounts that hospitals receive for treating patients with a particular disease or disorder.

In a preliminary decision in April, the Obama administration said it did not intend to pay extra for Blincyto because clinical studies were “not sufficient to demonstrate” that it substantially improved the treatment of Medicare patients with acute lymphoblastic leukemia, a cancer of the blood and bone marrow. Medicare officials said Amgen’s application was based on data from “a small sample group of patients whose age demographic is much younger than the age demographic of eligible Medicare beneficiaries.”

But in a final rule to be published in the Federal Register on Aug. 17, the administration says it received “additional information and input” from Amgen and other experts and now agrees with their arguments.

http://www.nytimes.com/2015/08/09/us/medicare-reversing-itself-will-pay-more-for-an-expensive-new-cancer-drug.html?hpw&rref=health&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well

Walk-in clinics force big medicine to rethink

By Priyanka Dayal McCluskey and Taryn Luna GLOBE STAFF AND GLOBE CORRESPONDENT 

When Christine Ryan’s ear was aching one recent afternoon, she didn’t head to the doctor’s office or emergency room; she went to her local CVS store in Cambridge.

Within 20 minutes, Ryan had been diagnosed with an ear infection and was picking up medicine and heading back to work. “This was the quickest visit I’ve ever had in my life,” the 24-year-old human resources professional said.

Consumers like Ryan increasingly are looking for faster and more convenient options to get basic medical care, and retailers like CVS are filling the gap with walk-in clinics and other services. That’s forcing traditional health care providers, from small doctors offices to big hospitals, to react.

At Atrius Health, a large medical group, more doctors are leaving their doors open until 8 p.m. Tufts Medical Center is taking online appointments for its emergency room. Several hospital networks are building walk-in clinics for urgent care. Doctors have started seeing patients through video chats. And apps are being built that will let consumers make appointments and view medical information from their phones, the way consumers already access so many other services.

“This represents a huge paradigm shift in health care,” said Normand E. Deschene, chief executive of Wellforce, the parent company of Tufts Medical Center and Lowell General Hospital. “The systems that are going to succeed are those that are going to embrace it because this is what the consumers want. Most industries follow what their consumers want. Health care should be no different.”

http://www.bostonglobe.com/business/2015/08/07/walk-clinics-are-forcing-big-medicine-rethink-retail-health-care/DUdP4usrTuVA2AIiJJfUHJ/story.html

The Opinion Pages  | EDITORIAL 

California Is Proving That Health Reform Works

By THE EDITORIAL BOARDAUG. 10, 2015

Californians got a double dose of good health care news late last month. The number of Californians who have trouble finding a doctor or paying their medical bills has sharply declined since the Affordable Care Act took effect. And premiums charged by private insurers have risen only modestly, contrary to warnings that insurers were likely to get double-digit premium increases.

In its latest survey tracking the experiences of California’s previously uninsured residents, the Kaiser Family Foundation reported that two-thirds of the uninsured had gained coverage through various programs, including the state’s Medicaid plan, employer-sponsored insurance and private policies bought on the new insurance exchange established by the state under the Affordable Care Act.

Those who remain uninsured in California rank health care costs as their top financial challenge, with 85 percent saying health insurance is difficult to afford, more than housing, gas or utilities. Among the recently insured, health care ranked fourth on their list of economic concerns, behind housing, utilities, and gas.

Meanwhile, Covered California, the state agency that runs the insurance exchange, announced that the average premium would rise only 4 percent next year, slightly less than the 4.2 percent increase for the current year.

California officials attributed the low rates to having a large number of enrollees (more than 1.3 million) in relatively good health, defying predictions that only the old and the sick would sign up. The state also benefited from a law giving the exchange power to decide which insurers can sell policies, which gives it leverage to demand lower rates. Since all insurers are required to provide a standard array of benefits and cost-sharing for various levels of coverage, consumers can focus on the two other issues of greatest concern: the price of the plan and whether it includes their preferred doctors.

http://www.nytimes.com/2015/08/10/opinion/california-is-proving-that-health-reform-works.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0

Coca-Cola Funds Scientists Who Shift Blame for Obesity Away From Bad Diets

By ANAHAD O’CONNOR

 AUGUST 9, 2015 5:25 PM

Coca-Cola, the world’s largest producer of sugary beverages, is backing a new “science-based” solution to the obesity crisis: To maintain a healthy weight, get more exercise and worry less about cutting calories.

The beverage giant has teamed up with influential scientists who are advancing this message in medical journals, at conferences and through social media. To help the scientists get the word out, Coke has provided financial and logistical support to a new nonprofit organization called the Global Energy Balance Network, which promotes the argument that weight-conscious Americans are overly fixated on how much they eat and drink while not paying enough attention to exercise.

“Most of the focus in the popular media and in the scientific press is, ‘Oh they’re eating too much, eating too much, eating too much’ — blaming fast food, blaming sugary drinks and so on,” the group’s vice president, Steven N. Blair, an exercise scientist, says in a recent video announcing the new organization. “And there’s really virtually no compelling evidence that that, in fact, is the cause.”

Health experts say this message is misleading and part of an effort by Coke to deflect criticism about the role sugary drinks have played in the spread of obesity and Type 2 diabetes. They contend that the company is using the new group to convince the public that physical activity can offset a bad diet despite evidence that exercise has only minimal impact on weight compared with what people consume.

http://well.blogs.nytimes.com/2015/08/09/coca-cola-funds-scientists-who-shift-blame-for-obesity-away-from-bad-diets/?emc=edit_tnt_20150809&nlid=1311158&tntemail0=y

Medicare finding ways to cover house calls and save money at once

August 7, 2015

by Diane Archer

Can Medicare deliver better care at home to older patients with multiple chronic conditions and save money in the process? Based on Year One practice results of Medicare’s Independence at Home Demonstration, the answer is a resounding “Yes.” In its first year, the Demonstration both improved health outcomes for patients with multiple chronic conditions and saved Medicare $25 million.

The Demonstration is funded through the Affordable Care Act with the goal of improving quality of care and quality of life for older patients with multiple care needs. It is designed to keep patients at home and out of institutions—be they hospitals or nursing home. The Demonstration gives doctors and nurse practitioners more time with their patients and allows them to assess their home environment. And, it is designed to improve both caregiver and patient satisfaction.

Patients in the Demonstration must be enrolled in traditional Medicare, have two or more chronic conditions and have been hospitalized in the prior 12 months. They receive comprehensive primary care tailored to their needs for a three-year period. The care team coordinates their care. The Centers for Medicare and Medicaid Services is tracking the patients’ care experiences through quality measures. Providers in the demonstration that succeed at reducing costs receive incentive payments.

Begun in 2012, fifteen sites throughout the country are engaged in this project, including Boston Medical Center, Cleveland Clinic Home Care Services, North-Shore Long Island Jewish Health Care and Dallas VPA.

http://justcareusa.org/medicare-finding-ways-to-cover-house-calls-and-save-money-at-once/

Vast majority of Americans want to expand Medicare and Social Security or keep spending as is

August 7, 2015

by Diane Archer

A new Kaiser Family Foundation survey of Americans reveals that the public views Medicare and Social Security as the two most important federal programs, slightly more important than federal aid to public schools and the military. Eighty-three percent of the public see Social Security as very important, and 77 percent see Medicare as very important.

In fact, 41 percent of people want to increase funding for Medicare (48 percent would keep spending where it is) and 50 percent of people want to increase spending for Social Security (43 percent would keep spending where it is). Check out this video to watch Robert Reich make the case for expanding Medicare.

Overall, seven of ten Republicans and independents and nine of ten Democrats see Medicare as very important. People over 65 value Medicare especially highly, regardless of party affiliation—85 percent of Republicans, 89 percent if independents and 92 percent of Democrats see Medicare as very important. Not surprisingly, people over 65 are more satisfied with their Medicare health insurance than people under 65 with their commercial insurance.

Support for Medicaid, a program for people with low incomes, differs more significantly based on party affiliation. Fewer than half of Republicans (47 percent) see Medicaid as very important, while 62 percent of independents and 78 percent of Democrats feel Medicaid is very important.

Read more here about Medicare coverage and the key differences between traditional Medicare and a private Medicare Advantage plan.

http://justcareusa.org/vast-majority-of-americans-want-to-expand-medicare-and-social-security/

Medicare is the solution to out of control health care costs, everyone should be able to buy into it

June 26, 2015

by Diane Archer

In a new two-minute video for MoveOn, Robert Reich makes the case for why Medicare is part of the solution to fixing our economy. We should be expanding it and offering it to everyone in America through the Affordable Care Act’s state health insurance exchanges. Seven out of ten likely voters (71 percent) support giving all Americans the choice of buying into Medicare as a way to drive competition in the health insurance marketplace.

Medicare is far more cost-effective than private health insurance. Because Medicare covers more than 50 million older adults and people with disabilities who need a lot of health care, the government is able to negotiate doctor and hospital rates that are lower than what the private insurers are able to negotiate. And, if Congress would lift the prohibition on Medicare negotiating drug prices with the drug companies, it would be able to bring those prices down as well.

At the same time, traditional Medicare gives people the option of seeing virtually any doctor and using almost any hospital in the country, in most instances, with no out-of-pocket costs so long as they have supplemental insurance or Medicaid. That’s why the overwhelming majority of people newly eligible for Medicare enroll in traditional Medicare.

http://justcareusa.org/medicare-is-the-solution-to-out-of-control-health-care-costs-everyone-should-be-able-to-buy-into-it/

Paying through the nose for prescription drugs

We pay far more for prescription medications than any other country – just the way Big Pharma and the insurance industry likes it

• By Wendell Potter
• August 8, 2015
• Now that the campaigns for president are in full swing, with the first Republican debate behind us, we can expect to hear plenty over the coming months about what we as a nation must do about our health care system, especially what we must do to make sure that the Medicare program will still be around for future generations. The candidates’ proposals will run the gamut from expanding the program to encompass every one of us – regardless of age – to scrapping it altogether and replacing it with, well something.
  Former Florida Governor Jeb Bush, for one, appears to be in the second camp. He made headlines a few days ago when he said during a Koch Brothers gathering in New Hampshire that, because of increasing health care costs, the time may have come for lawmakers to consider dismantling Medicare as we know it.
  “We need to make sure we fulfill the commitment to people that have already received the benefits, that are receiving the benefits.” said Bush. “But we need to figure out a way to phase out this program for others and move to a new system that allows them to have something, because they’re not going to have anything.”
  His implication was that the Medicare program’s current level of spending is unsustainable. One thing he didn’t mention, however, is that his brother is at least partly responsible for the fact that Medicare now has to spend more than it otherwise would, a situation that is penalizing both Medicare beneficiaries and all of us who pay taxes.
  http://www.medicareresources.org/blog/2015/08/08/paying-through-the-nose-for-prescription-drugs/#.Vcjej_7dUao.facebook
  
  

  Bill calls for limit on drug prices

  Mass. bill seeks to rein in prices of some drug

  By Robert Weisman GLOBE STAFF  AUGUST 10, 2015

  Drug companies are facing a new campaign to contain treatment costs, this time with proposed rules in Massachusetts that would include a first-in-the-nation cap on some prices.

  An alliance of lawmakers, consumers, and health insurers is pushing for a law that would force biotechnology and pharmaceutical companies to justify their prices by disclosing how much they spend on research, production, and marketing. It also would allow the state’s Health Policy Commission to limit the prices of especially costly drugs, something not done anywhere in the country.

  “Drug prices are by far the fastest-growing part of health care costs,” said Brian Rosman, research director at Health Care for All, a Boston consumer advocacy group that helped draft the Massachusetts bill. “The whole system is a black box. There is very little ability for consumers who go to a pharmacy and pay a copay to understand whether it’s a fair price.”

  Similar “transparency” legislation has been filed in New York, California, Pennsylvania, Texas, North Carolina, and Oregon, though the specifics of each bill vary.

  One driver of the effort has been America’s Health Insurance Plans, the national insurance trade group.

  The efforts come amid a growing backlash against price tags of tens of thousands or hundreds of thousands of dollars a year for some medicines that treat cancers and rare diseases.

  Last month, a group of prominent doctors and scientists objected to a $259,000 annual price set by Boston’s Vertex Pharmaceuticals Inc. for a new cystic fibrosis drug. The same week, in a medical journal, more than 100 leading oncologists protested a rise in cancer drug prices.

  Sanofi SA and Regeneron Pharmaceuticals Inc. last month priced their new cholesterol-lowering drug at $14,600 a year, twice as much as many health plans had anticipated.

  “We need to get under the hood and understand what goes into these prices,” said Lora Pellegrini, president of the Massachusetts Association of Health Plans, a trade group for health insurers that worked with Health Care for All on the transparency bill.

  http://www.bostonglobe.com/business/2015/08/10/state-lawmakers-backed-consumers-and-health-plans-seek-rein-prescription-drug-costs/xfzRkTt2xFGRibEHkPOoYM/story.html?s_campaign=email_BG_TodaysHeadline&s_campaign=

  
  

  National Nurses United Endorses Senator Bernie Sanders for President

  Caring, compassion, and community. These are the values at the heart of registered nursing. This is true at the bedside, as nurses advocate for patients and families—and also beyond the walls of the hospital, as RNs call for environmental, racial, and economic justice in the name of public health. National Nurses United, which represents some 190,000 nurses nationwide, seeks to uphold that positive vision for the health of this country by endorsing Senator Bernie Sanders for president. #nurses4bernie

  Here are 10 reasons why National Nurses United endorses Bernie Sanders:

  1. 100% IN ALIGNMENT WITH WHAT MATTERS MOST TO RNS.

  On an NNU questionnaire sent to all presidential candidates, Sanders was the only one to score 100 percent in alignment with NNU’s values. NNU leadership recommended his endorsement to membership—who overwhelmingly supported Sanders in a poll.

  2. BUILDING A SOCIAL MOVEMENT TO HEAL AMERICA.

   Sanders echoes nurses’ values and the social movements of our time, for healthcare for all, for jobs at living wages, for fighting income inequality, for educational opportunity, for environmental justice and action on the climate crisis, for civil rights, voting rights, and ending the systemic racism in policing and the criminal justice system.  His campaign offers an opportunity to unify those movements to build a more humane America.

  3. CALLING FOR MANDATORY, FEDERAL NURSE-TO-PATIENT RATIOS.

   There are no mandatory limits on how many patients can be assigned to an RN in almost all U.S. hospitals, despite study after study showing a direct link between safe RN staffing levels and patient outcomes. California is the only state with such “ratios” laws, won by NNU RNs after years of battling the powerful hospital lobby. Sanders is cosponsoring a federal bill, S. 864, that would mandate ratios for all U.S. hospitals, and it is one of a number of federal and state ratios bills that NNU is pursuing. 

  4. LEADING THE WAY IN MEDICARE FOR ALL.

  Too many Americans, even with the Affordable Care Act, remain priced out of access to necessary healthcare. Sanders champions what RNs agree is real reform: an improved, expanded Medicare for all.

  5. HOLDING WALL STREET ACCOUNTABLE.

  With a vision of economic justice, Sanders has demanded Wall Street pay its fair share of taxes and introduced the NNU-backed Robin Hood Tax bill, S. 1731, that, through a 0.5 percent tax on stock market speculation, could raise hundreds of billions to pay for healthcare for all, free college tuition, more living-wage jobs at living wages, ending AIDS, real action against the climate crisis, and other basic needs.

  6. PROTECTING VA NURSES.

  Sanders is a cosponsor of the VA Employee Fairness Act (S. 1257/H.R. 2193), an NNU-backed bill that would allow VA nurses to collectively bargain for better wages and working conditions like other VA employees already do.

  7. VOICING STRONG OPPOSITION TO THE TRANS PACIFIC PARTNERSHIP (TPP).

  Sanders also stands out in his outspoken, public opposition to the Trans-Pacific Partnership, which—besides posing serious threats to the environment, food safety, and workers’ rights—would allow pharmaceutical giants to drive up drug prices, a life-and-death issue for millions.

  8. PROTECTING WORKERS.

  “Bernie Sanders has a proven track record of uncompromised activism and advocacy for working people,” says NNU Executive Director RoseAnn DeMoro, who cites his strong opposition to right-to-work laws and willingness to veto a national right-to-work bill.

  9. OPPOSING THE KEYSTONE XL PIPELINE.

  Sanders has vocally opposed and voted against all attempts by Congress to approve the Keystone XL pipeline, an example of activities RNs oppose because they worsen climate change and jeopardize public health.

  10. TAKING ON SYSTEMIC RACISM.

  NNU recently released a statement on Black Lives Matter and the health impact of societal racial disparities, urging all presidential candidates to address systemic racism and economic inequality. Sanders has done just that, recently declaring that many of the unarmed African Americans killed by police over this past year probably would not have been “if they were white” and calling for demilitarization of the country’s police departments.

  
  

  http://www.nationalnursesunited.org/site/entry/vote-nurses-values

  
  

  Number of Uninsured Has Declined by 15 Million Since 2013, Administration Says

  By ROBERT PEARAUG. 12, 2015

  
  

  WASHINGTON — The number of people without health insurance continues to decline and has dropped by 15.8 million, or one-third, since 2013, the Obama administration said Tuesday.

  The decline occurred as major provisions of the Affordable Care Act took effect. The law expanded coverage through Medicaid and through subsidies for private insurance, starting in 2014.

  In the first three months of this year, the National Center for Health Statistics said, 29 million people were uninsured. That was seven million fewer than the average for 2014, after a reduction of 8.8 million from 2013 to 2014.

  The data may bolster Democrats’ claims that the law is working as they intended, but it is unlikely to prompt Republicans to let up on criticism of the law, which was passed without any Republican votes.

  In a report on its findings, the center said that the proportion of the population without insurance had declined by five percentage points, to 9.2 percent, in the first quarter of this year, from 14.4 percent in 2013.

  Among people age 18 to 64, the number who were uninsured dropped by about one-third, to 25.5 million, in the first quarter of this year, from 39.6 million in 2013. And among children under 18, the number of uninsured declined to 3.4 million this year, from 4.8 million in 2013.

  The decline in the number of uninsured coincides with improvements in the economy. In the last two years, the recovery has gained traction and the unemployment rate has declined steadily.

  The numbers for the first quarter of this year, from the National Health Interview Survey, are estimates based on data for 26,121 people. The information was collected in household interviews by the Census Bureau, using procedures specified by the National Center for Health Statistics, a part of the Public Health Service. The survey focused on the civilian population outside prisons and nursing homes.

  The report suggests that the Affordable Care Act produced the most significant gains in coverage among poor people and those with income just over the poverty level, which is $11,770 for an individual.

  http://www.nytimes.com/2015/08/12/us/number-of-uninsured-has-declined-by-15-million-since-2013-administration-says.html?hp&action=click&pgtype=Homepage&module=second-column-region&region=top-news&WT.nav=top-news

  
  

  
  

  Maine’s uninsured 
rate drops
 but 
remains highest in New England, poll shows

  Experts say Maine's 9.4 percent rate is unlikely to improve much without a Medicaid expansion, which Gov. Paul LePage opposes.

  BY JOE LAWLOR STAFF WRITER

  Maine’s uninsured rate declined during the first six months of 2015, but the state nevertheless has the highest percentage of adults without health benefits in New England, according to a Gallup poll released Monday.

  Although the percentage of uninsured declined from 11.6 percent in 2014 to 9.4 percent through the first six months of 2015, New Hampshire’s rate dropped from 12.8 in 2014 to 8.7 percent this year. Maine’s uninsured rate stood at 16.1 percent in 2013, the last year before the Affordable Care Act’s health insurance marketplace – the system where individuals can purchase subsidized insurance – went into effect.

  “This is good news for Maine in that it shows the ACA is in place, it’s working and people are getting covered,” said Wendy Wolf, president and CEO of the Maine Health Access Foundation, a nonprofit that strives to improve health insurance coverage.

  But all other New England states now have lower uninsured rates than Maine – and four states boast 5 percent or less of the population without health insurance. Rhode Island’s 2.7 percent uninsured is the lowest in the nation, followed closely by Massachusetts at 3 percent.

  Maine’s 9.4 percent uninsured rate for 2015 is still better than the national average of 11.7 percent – down from 17.3 percent in 2013. Twenty-one states have a lower uninsured rate than Maine, according to Gallup.

  Wolf said Maine’s high number of people who are self-employed or work for small businesses that don’t offer health benefits has meant Mainers have embraced the ACA’s health insurance marketplace, with 75,000 people signing up for benefits. But there are still thousands of low-income people who don’t qualify for ACA subsidies, and therefore could not afford marketplace insurance, Wolf said, limiting the impact of President Obama’s signature health care law in Maine.

  Maine has also tightened Medicaid eligibility, reducing the number of people on the program.

  Meanwhile, New Hampshire approved Medicaid expansion in 2014 – passing a compromise plan to attract Republican votes – while Maine has so far spurned expansion, due to Gov. Paul LePage’s opposition. Medicaid provides insurance for low-income residents.

  Twenty-eight states have passed Medicaid expansion, with Maine the only New England state to reject expansion. Wolf said New Hampshire’s rate of uninsured likely declined at a faster pace than Maine’s because of the decision to expand Medicaid.

  http://www.pressherald.com/2015/08/10/health-insurance-rate-maine-improves-many-still-go-without-polls-shows/

  
  

  Labels Like ‘Alternative Medicine’ Don’t Matter. The Science Does.

  AUG. 10, 2015

  
  

  The University of Toronto recently stirred up a bit of controversy by offering an uncritical class on “Alternative Medicine.” A variety of bloggers and journalists brought up many valid concerns about the curriculum, but there is a much larger problem: No one is sure how best to teach that subject.

  The dichotomy, however, between alternative and traditional medicine, or between Eastern and Western medicine, is a false one. We would be much better off if we could reframe the issue.

  People often think of Eastern or alternative medicine as more “natural.” Many feel that Western medicine is built around technology and products produced in a lab. They’re not entirely wrong. Many of the gains that have been made in traditional medicine have been the result of innovation in laboratories.

  But that doesn’t mean that everything doctors are taught in medical school involves a drug or device. I talk to patients all the time about diet and exercise. I don’t do this because there’s a company making money off it. I do it because both of these things have been proven to be important for health.

  Nor do all medications get cooked up in a lab. We recommend folic acid, which is a B Vitamin, for pregnant women because research has shown that it reduces the risk of major birth defects in newborns. We all know that adequate intake of vitamin C prevents scurvy and that vitamin D prevents rickets.

  None of these things are controversial to physicians. We recommend them all the time. That’s not because they were developed in the Western Hemisphere. It’s because they have been subjected to the rigor of scientific investigation — and found to have merit.

  There are many other forms of nontechnological medicine that have the weight of scrutiny behind them. In a meta-analysis published just a few years ago, researchers looked at all the accumulated randomized controlled trials examining how acupuncture fared in treating people with chronic pain. They found that not only did acupuncture work better than no-acupuncture control groups, but there were also significant differences between acupuncture and sham acupuncture. This suggests that not all of the benefits are placebo effects.

  People have been treating many mental health problems with therapy for years. Full disclosure: I’m one who has been treated. I’ve never taken any of the long-term psychotropic drugs, and many patients prefer not to if possible. Austin Frakt, my Upshot co-contributor, wrote recently about the evidence supporting cognitive behavioral therapy for insomnia, as well as for a host of other health problems. Even mindfulness, or meditation, has been studied extensively, and found to be pretty effective in treating anxiety and mood problems. I’ve been convinced enough by this evidence to try meditation myself.

  http://www.nytimes.com/2015/08/11/upshot/labels-like-alternative-medicine-dont-matter-the-science-does.html?em_pos=small&emc=edit_up_20150811&nl=upshot&nlid=1311158&ref=headline&abt=0002&abg=0