So Nancy, after hard bargaining against Trump's sloppy initial NAFTA revamp,
Senate passes USMCA, but much work remains
It’ll take years of costly work before American workers and businesses begin to benefit from the new trade pact with Mexico and Canada.
By SABRINA RODRIGUEZ 01/16/2020 11:51 AM EST Updated: 01/16/2020 01:34 PM EST
[...]
Some Democrats, including Senate Minority Leader Chuck Schumer and Sens. Kamala Harris of California, Cory Booker of New Jersey and Bernie Sanders of Vermont, voted against the pact for not doing enough to protect American jobs or address environmental issues.
"Despite the fact that it includes very good labor provisions, I am voting against USMCA because it does not address climate change, the greatest threat facing the planet," Schumer said.
Democrats worked into the deal stronger labor enforcement provisions that will help ensure companies operating in Mexico boost workers' rights and give the U.S. the power to punish them if they violate labor rights.
Some of the top labor changes that won over Democrats include provisions that will allow the U.S. to file complaints against Mexican factories suspected of violating workers’ union rights. The revised USMCA would allow the U.S. to be part of a multinational team that verifies whether factories are complying and can penalize them if they do not.
Mexico had to make significant concessions in order to land the deal — and that meant a series of intense and often heated talks with U.S. Trade Representative Robert Lighthizer.
[...]
The final deal was the product of almost six months of negotiations between the Trump administration and House Democrats to address prevailing Democratic concerns on the pact’s enforcement, environment, labor and pharmaceutical provisions.
Democrats succeeded in getting the Trump administration to drop a provision establishing a 10-year protection period for biologic drugs, which opponents say would have allowed drug companies to keep prices high. That change left some Republicans and business groups disappointed, but not enough to withdraw support for the deal.
Still, the deal is not expected to significantly increase trade within the region. The original NAFTA, which Trump has long regarded as the “worst trade deal ever made,” already eliminated most tariffs between the U.S., Mexico and Canada.
“It’s a modest upgrade from what we had before, but of course, Trump is overstating the deal. And he’s going to get away with overstating because Democrats want to oversell it on how they got all these improvements,” said Bill Reinsch, a trade expert with the Center for Strategic and International Studies.
“Everybody is overselling it,” Reinsch added.
The USMCA, which Trump has called “the best and most important trade deal ever made by the USA,” would raise U.S. GDP by $68.2 billion, or 0.35 percent, by the sixth year after it enters into force, according to the independent U.S. International Trade Commission.
The president on Wednesday blamed a federal agency decision during Barack Obama’s presidency, which Trump said made it harder to quickly roll out testing for the virus.
“The Obama administration made a decision on testing that turned out to be very detrimental to what we’re doing, and we undid that decision a few days ago so that the testing can take place in a much more accurate and rapid fashion,” he told reporters during a White House meeting with airline executives, whom he had called to discuss the economic effects of the outbreak.
“That was a decision we disagreed with,” he said. “I don’t think we would have made it, but for some reason, it was made.”
It was unclear what decision Trump was referring to. Robert Redfield, the director of the Centers for Disease Control and Prevention (CDC), said private laboratories used to be able to develop clinical tests but “in the previous administration that became regulated. For someone to do that they had to file with the FDA”, Redfield said.
But experts on lab testing have said they are unaware of an Obama administration rule that would have hindered the use of tests developed at university or private labs in an emergency.
The responsibility for the coronavirus test kit shortage appears to lie with the CDC’s choice to develop and distribute its own kit rather than use the one recommended by the World Health Organization, according to ProPublica .. https://www.propublica.org/article/cdc-coronavirus-covid-19-test . But the CDC’s tests didn’t work, falsely flagging harmless samples that contained viruses other than Covid-19.
Trump attacked Democrats for warning of the seriousness of the crisis while spreading disinformation and downplaying the outbreak, his critics have said.
Two days before he was announced as a member of the White House taskforce on coronavirus, Larry Kudlow, the director of the National Economic Council, declared coronavirus “contained” in the US, despite a plethora of data that suggested it was not.
“I won’t say airtight, but it’s pretty close to airtight,” Kudlow told CNBC, swaddling himself in a comforting narrative that was probably destroyed in his first meeting with the task force.
“If efforts are being made to muzzle them, to control messaging so that it suits the political needs of the administration,” Michael Carome of Public Citizen, a not-for-profit consumer advocacy organization, said, “that’s ultimately going to endanger the public.”
A decade of telemedicine policy has advanced in just 2 weeks
"Pelosi Humiliates Trump With Coronavirus Response Bill [...] To protect public health, the bill will allow Medicare providers to extend telemedicine services to seniors regardless of where they live, at an estimated cost of $500 million."
Publish date: April 6, 2020
Author(s): Maureen Salamon
The rapid spread of COVID-19 forced Seemal Desai, MD, to make an excruciating choice; he could either shutter his busy dermatology practice in Plano, Tex., or switch most patient consults to telemedicine, which he’d never used.
“Kaboom! We made the decision to start doing it,” he said in an interview. “We drafted a consent form, uploaded it to our website, called patients, changed our voice greeting, and got clarity on insurance coverage. We’ve been flying by the seat of our pants.”
“I’m doing it because I don’t have a choice at this point,” said Dr. Desai, who is a member of the American Academy of Dermatology board of directors and its coronavirus task force. “I’m very worried about continuing to be able to meet our payroll expenses for staff and overhead to keep the office open.”
“Flying by the seat of our pants” to see patients virtually
Dermatologists have long been considered pioneers in telemedicine. They have, since the 1990s, capitalized on the visual nature of the specialty to diagnose and treat skin diseases by incorporating photos, videos, and virtual-patient visits. But the pandemic has forced the hands of even holdouts like Dr. Desai, who clung to in-person consults because of confusion related to HIPAA compliance issues and the sense that teledermatology “really dehumanizes patient interaction” for him.
In fact, as of 2017, only 15% of the nation’s 11,000 or so dermatologists had implemented telehealth into their practices, according to an AAD practice survey .. https://jamanetwork.com/journals/jamadermatology/fullarticle/2607375 . In the wake of COVID-19, however, that percentage has likely more than tripled, experts estimate.
Now, dermatologists are assuming the mantle of educators for other specialists who never considered telehealth before in-person visits became fraught with concerns about the spread of the virus. And some are publishing guidelines for colleagues on how to prioritize teledermatology to stem transmission and conserve personal protective equipment (PPE) and hospital beds.
User-friendly technology and the relaxed telehealth restrictions have made it fairly simple for patients and physicians to connect. Facetime and other once-prohibited platforms are all currently permissible, although physicians are encouraged to notify patients about potential privacy risks, according to an AAD teledermatology tool kit .. https://www.aad.org/member/practice/telederm/toolkit .
Teledermatology innovators
“We’ve moved 10 years in telemedicine policy in 2 weeks,” said Karen Edison, MD .. https://www.muhealth.org/doctors/karen-edison-md , of the University of Missouri, Columbia. “The federal government has really loosened the reins.”
Dr. Karen Edison
At least half of all dermatologists in the United States have adopted telehealth since the pandemic emerged, she estimated. And most, like Dr. Desai, have done so in just the last several weeks.
“You can do about 90% of what you need to do as a dermatologist using the technology,” said Dr. Edison, who launched the first dermatology Extension for Community Healthcare Outcomes, or ECHO, program in the Midwest. That telehealth model was originally developed to connect rural general practitioners with specialists at academic medical centers or large health systems.
“People are used to taking pictures with their phones. In some ways, this crisis may change the face of our specialty,” she said in an interview.
“As we’re all practicing social distancing, I think physicians and patients are rethinking how we can access healthcare without pursuing traditional face-to-face interactions,” said Ivy Lee, MD .. https://www.directderm.com/our-doctors/ivy-lee/ , from the University of California, San Francisco, who is past chair of the AAD telemedicine task force and current chair of the teledermatology committee at the American Telemedicine Association. “Virtual health and telemedicine fit perfectly with that.”
Even before the pandemic, the innovative ways dermatologists were using telehealth were garnering increasing acclaim. All four clinical groups short-listed for dermatology team of the year .. https://www.bmj.com/content/368/bmj.m748.full .. at the BMJ Awards 2020 .. https://thebmjawards.bmj.com/ .. employed telehealth to improve patient services in the United Kingdom.
In the United States, dermatologists are joining forces to boost understanding of how telehealth can protect patients and clinicians from some of the ravages of the virus.
The Society of Dermatology Hospitalists has developed an algorithm – built on experiences its members have had caring for hospitalized patients with acute dermatologic conditions – to provide a “logical way” to triage telemedicine consults in multiple hospital settings during the coronavirus crisis, said President-Elect Daniela Kroshinsky .. https://www.massgeneral.org/children/doctors/17663/daniela-kroshinsky , MD, from Massachusetts General Hospital in Boston.
Telemedicine consultation is prioritized and patients at high risk for COVID-19 exposure are identified so that exposure time and resource use are limited and patient and staff safety are maximized.
“We want to empower our colleagues in community hospitals to play a role in safely providing care for patients in need but to be mindful about preserving resources,” said Dr. Kroshinsky, who reported that the algorithm will be published imminently.
“If you don’t have to see a patient in person and can offer recommendations through telederm, you don’t need to put on a gown, gloves, mask, or goggles,” she said in an interview. “If you’re unable to assess photos, then of course you’ll use the appropriate protective wear, but it will be better if you can obtain the same result” without having to do so.
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Sharing expertise
After the first week of tracking data to gauge the effectiveness of the algorithm at Massachusetts General, Dr. Kroshinsky said she is buoyed.
Of the 35 patients assessed electronically – all of whom would previously have been seen in person – only 4 ended up needing a subsequent in-person consult, she reported.
“It’s worked out great,” said Dr. Kroshinsky, who noted that the pandemic is a “nice opportunity” to test different telehealth platforms and improve quality down the line. “We never had to use any excessive PPE, beyond what was routine, and the majority of patients were able to be staffed remotely. All patients had successful outcomes.”
Dr. Carrie L. Kovarik
With telehealth more firmly established in dermatology than in most other specialties, dermatologists are now helping clinicians in other fields who are rapidly ramping up their own telemedicine offerings.
These might include obstetrics and gynecology or “any medical specialty where they need to do checkups with their patients and don’t want them coming in for nonemergent visits,” said Carrie L. Kovarik, MD .. https://www.pennmedicine.org/providers/profile/carrie-kovarik , of the University of Pennsylvania, Philadelphia.
In addition to fielding many recent calls and emails from physicians seeking guidance on telehealth, Dr. Kovarik, Dr. Lee, and colleagues have published the steps required .. https://www.jaad.org/article/S0190-9622(20)30472-2/fulltext .. to integrate the technology into outpatient practices.
“Now that there’s a time for broad implementation, our colleagues are looking to us for help and troubleshooting advice,” said Dr. Kovarik, who is also a member of the AAD COVID-19 response task force.
Various specialties “lend themselves to telehealth, depending on how image- or data-dependent they are,” Dr. Lee said in an interview. “But all specialists thinking of limiting or shutting down their practices are thinking about how they can provide continuity of care without exposing patients or staff to the risk of contracting the coronavirus.”
After-COVID goals
In his first week of virtual patient consults, Dr. Desai said he saw about 75 patients, which is still far fewer than the 160-180 he sees in person during a normal week.
“The problem is that patients don’t really want to do telehealth. You’d think it would be a good option,” he said, “but patients hesitate because they don’t really know how to use their device.” Some have instead rescheduled in-person appointments for months down the line.
Although telehealth has enabled Dr. Desai to readily assess patients with acne, hair loss, psoriasis, rashes, warts, and eczema, he’s concerned that necessary procedures, such as biopsies and dermoscopies, could be dangerously delayed. It’s also hard to assess the texture and thickness of certain skin lesions in photos or videos, he said.
“I’m trying to stay optimistic that this will get better and we’re able to move back to taking care of patients the way we need to,” he said.
Like Dr. Desai, other dermatologists who’ve implemented telemedicine during the pandemic have largely been swayed by the relaxed CMS regulations. “It’s made all the difference,” Dr. Kovarik said. “It has brought down the anxiety level and decreased questions about platforms and concentrated them on how to code the visits.”
And although it’s difficult to envision post-COVID medical practice in the thick of the pandemic, dermatologists expect the current strides in telemedicine will stick.
“I’m hoping that telehealth use isn’t dialed back all the way to baseline” after the pandemic eases, Dr. Kovarik said. “The cat’s out of the bag, and now that it is, hopefully it won’t be put back in.”
“If there’s a silver lining to this,” Dr. Kroshinsky said, “I hope it’s that we’ll be able to innovate around health care in a fashion we wouldn’t have seen otherwise.”
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