#i would defend colt w my life actually…

[kmfdmvr]

duality of man

[yhwhsdaughter]

How problematic are they? Would they get cancelled?

content: cursing, mild spoilers, insulting your faves, long list of characters

EREN ˚₊· ͟͟͞͞➳❥ soooo problematic and for what? in his defense, eren doesn’t actively try to come off as an asshole— he just has strong opinions and doesn’t really care if it rubs people the wrong way

MIKASA *ೃ༄ my girl out here getting hate for no reason. haters are just afraid because mikasa is a strong, independent woman who doesn’t care for their stupid comments

ARMIN ˚₊· ͟͟͞͞➳❥ armin is perfect, he can do wrong in my eyes. he’s the golden child of attack on titan. i dont accept criticism on this sorry

JEAN *ೃ༄ mmm yes but no; people would probably just give him shit because a video surfaced of him treating his mom kinda badly. some defend him and others don’t

CONNIE ˚₊· ͟͟͞͞➳❥ because he’s just a crackhead, connie might accidentally say something offensive. his manager will have to apologize on his behalf because he’d probably fuck it up and make it worse lmao

SASHA *ೃ༄ gets hateful comments because she’s unapologetically herself— doesn’t quite care for bullshit societal norms and does what she wants, which sometimes gets her in trouble

MARCO ˚₊· ͟͟͞͞➳❥ this man doesn’t have a mean bone in his body, someone protect him. if anything, he might just get caught in jean’s drama at times

HISTORIA *ೃ༄ publicly, she’s okay but i feel like she’d have some really dark and questionable morals on the downlow

YMIR ˚₊· ͟͟͞͞➳❥ misandrist. she’s not sorry either sjsjsjsj

ANNIE *ೃ༄ doesn’t really fuck with people. annie is the definition of “minding my business” but if someone gets on her bad side, bitch won’t be afraid to bring out the receipts

REINER ˚₊· ͟͟͞͞➳❥ made a lot of bad decisions when he was young and now they’ve come back to bite him in the ass. he’s really just trying to live his life but people will bring back shit he did like 5 years ago

BERTHOLDT *ೃ༄ others have done worse shit than him but ppl just focus on one bad thing he did. like, they won’t let go no matter how much time has passed. tries to handle it with grace but kinda snaps

LEVI ˚₊· ͟͟͞͞➳❥ do no harm but take no shit. levi might get a bad rep but he’s perhaps one of the least problematic characters. looks like he could shit in your dinner (and would) but only if you deserve it.

HANGE *ೃ༄ kinda crazy. hange is living life to the fullest, sometimes threading in dangerous territory but they are not offensive in general.

ERWIN ˚₊· ͟͟͞͞➳❥ my man is no angel, he’s done his fair share of problematic shit but somehow smooth talks his way out of punishments??

FLOCH *ೃ༄ he’s easy to hate. mostly cuz he’s a shitty person but partly because he looks so annoying.

MARLO ˚₊· ͟͟͞͞➳❥ he’s the one cancelling people. jk, marlo would try his best to be a good role model and dislikes cancel culture because he thinks it doesn’t teach people to be better by learning from their mistakes (this varies on the situation)

KENNY *ೃ༄ drunk uncle that can beat your ass no matter how old he gets. not a good parental role either!! homo— sexual? phobic?

RICO ˚₊· ͟͟͞͞➳❥ this waifu might seem like a bit of a hardass with unsavory opinions but doesn’t have malicious intent so we give her a pass.

PIECK *ೃ༄ homegirl is asleep most of the time. she doesn’t have the energy to be problematic.

PORCO ˚₊· ͟͟͞͞➳❥ porco acts really high and mighty for someone who’s quite problematic. always starts beef with reiner. it’s so random too, like ??

MARCEL *ೃ༄ the better twin. not problematic whatsoever. he’s actually the one who deescalates his brother’s fights. bless him

COLT & FALCO ˚₊· ͟͟͞͞➳❥ really wholesome siblings and people in general. they’ve never done anything wrong in their life, ever.

GABI *ೃ༄ for a child, she gets a lot of hate. gabi doesn’t quite fully understand the adult world so she might say or do things that bother people. doesn’t mean she deserves the hate but anyway—

YELENA ˚₊· ͟͟͞͞➳❥ a culprit by association. adores zeke at an unhealthy level and condones all the bad shit he’s done. knows the diff between right and wrong but ignores it. may or may not have mafia connections

ZEKE *ೃ༄ zeke is the type of person who’s in the wrong but refuses to admit it. his way or the highway.

ONYANKOPON ˚₊· ͟͟͞͞➳❥ he’s an unproblematic king. wouldn’t be afraid to apologize or own up to his errors and that’s why we stan

TYBUR *ೃ༄ probably an incel. despite the obvious red flags, i feel like he’d manage to gaslight people into thinking he’s a good person. probably a cult leader too

NICCOLO ˚₊· ͟͟͞͞➳❥ “you punch a couple hundred orphans and suddenly you’re mean” niccolo took ryan reynold’s a little too seriously. he’s gordon ramsey w/ everyone except sasha

GRISHA *ೃ༄ uhh well he’s not winning father of the year award anytime soon. grisha has made some mistakes and sorta learned from them? he’s trying his best but he’s on thin fucking ice

CARLA ˚₊· ͟͟͞͞➳❥ unlike her son, miss carla wouldn’t get cancelled. everybody loves this milf (as they should). horny thoughts aside, she’s actually really sweet

REINER’S PARENTS *ೃ༄ i’d label them as the worst parents in aot but that title is reserved for historia’s parents. anyway, these mfs would have CPS on their asses since day 1

HISTORIA’S PARENTS ˚₊· ͟͟͞͞➳❥ crème de la crème of being asshole parents. CEOs of shitty parenting. everyone hates them and for good reason.

[insurancepolicypro]

Sickened By Billing Abuses, Readers And Tweeters Stand Up For Sufferers’ Rights

Letters to the Editor is a periodic function. We welcome all feedback and can publish a range. We edit for size and readability and require full names.

Personal Fairness Predators?

To begin with, let me thanks for writing about such an essential problem (“Buyers’ Deep-Pocket Push To Defend Shock Medical Payments,” Sept. 11). I’m going to inform you about my private ache relating to shocking medical billing.

They’ll name themselves Physician Affected person Unity group or every other fancy title, however the actuality is that they’re all predators. I say this as a result of I’m the sufferer of those medical doctors teams. I work as a linguist with the U.S. Military and have top-secret clearance. I might lose my clearance if any of my payments go to a collections company.

I had appendix surgical procedure on Nov. 6, 2018, on the Davis Medical Heart in Layton, Utah. The surgeon had informed me that my surgical procedure would take solely 10 to 15 minutes. After two hours of surgical procedure, I used to be launched from the hospital and despatched dwelling. My insurer, CIGNA, paid all of the Davis hospital payments and I paid my portion of the payments. Then in March 2019, I obtained two separate physician’s payments totaling about $48,000. My insurance coverage was not paying the physician’s payments as a result of they had been out-of-network. The physician’s workplace saved sending me letters to pay $48,000 from my pocket; if I didn’t pay, I used to be informed, my payments can be despatched to collections.

Lastly, I obtained a letter from the collections company saying that if I didn’t pay $26,770, it will ship the data to the credit score companies. Can the Physician Affected person Unity group inform me what I ought to do? Ought to I lose my clearance and my job as a result of I can not afford to pay $26,770? Ought to I borrow cash from the financial institution after which pay excessive curiosity to the financial institution for the remainder of my life?

— Aziz Rehman, Kaysville, Utah

It is a very deceptive article. Many impartial physicians talking out need IDR to resolve the issue of outliers and take sufferers #OutOfTheMiddle. Insurance coverage-backed lobbyists are utilizing this problem as a #TrojanHorse to counterpoint company shareholders at expense of physicians.

— Amy Mecozzi Cho, MD MBA (@amychomd) September 12, 2019

On Twitter, Dr. Amy Mecozzi Cho of Minneapolis identified holes within the article. For instance, she informed KHN, “the contracted charges for insurance coverage are deceptive since our dangerous debt for sufferers with high-deductible insurance coverage is bigger than 60% of their deductible, however insurance coverage corporations gained’t invoice them as a result of they know this. And so our efficient charges for business insurance coverage are literally a lot decrease than contracted. The medical loss ratio and the CBO estimates aren’t capturing these prices to sufferers and physicians.”

Non secular Malpractice

My sister, a hospital chaplain (of Roman Catholic religion), informs me that it’s thought-about chaplain malpractice to attempt to power a affected person to deal with struggling within the precise method others assume they need to (“Firing Physician, Christian Hospital Units Off Nationwide Problem To Assist-In-Dying Legal guidelines,” Aug. 30). It might observe, then, hospital’s requiring employees to “assist” sufferers “recognize the Christian understanding of redemptive struggling” is a paternalistic dismissal of affected person integrity and a type of malpractice. The medical relationship is between the affected person and the physician, not the affected person and the Vatican.

— Gloria Kohut, Grand Rapids, Mich.

Many hospitals in India are managed by non secular organisations (Hindu, Jain, Christian, Muslim) Are in addition they as illiberal to variations in a single’s method to what’s moral in medical observe because the Christian hospital on this case? https://t.co/Nzy6JN348B

— Amar Jesani (@amarjesani) September eight, 2019

— Amar Jesani, Mumbai, India

It’s unfathomable that college students with disabilities can’t get the help they should attend faculty and dwell in the neighborhood! Bravo to this Stanford freshman for combating for providers. It’s previous time for available assist for college kids! #DisabilityRightshttps://t.co/EuVnUzEX8b

— Areva Martin, Esq. (@ArevaMartin) September 2, 2019

— Areva Martin, Los Angeles

Squeezing The Most Out Of Scholar Assist

I noticed Jenny Gold’s wonderful article within the Los Angeles Instances a few disabled pupil’s want for help as she begins faculty at Stanford (“Highlight: A Younger Girl, A Wheelchair And The Combat To Take Her Place At Stanford,” Sept. four). I wished you to bear in mind that the Division of Rehabilitation in California pays for added bills for college kids to coach them for future employment. This contains laptops, provides, transportation bills, mandatory bills. They could additionally pay for bills for care above and past the approval of the state Division of Well being Care Providers.

All college students face the difficulty of assist themselves whereas in faculty. Stanford’s pretty present of training for all who’re accepted is commonly not used because of the excessive bills of that space. Many college students are unable to afford faculty, even with a full scholarship.

Those that have paid their method with pupil loans and are actually employed in excessive service areas, akin to drugs, psychiatry, social providers and instructing, are strapped with lifetime funds. Our greatest and our brightest who serve our communities are in debt to the purpose the place their earnings barely pays their lifetime of pupil loans. Sylvia Colt-Lacayo’s state of affairs could have extra bills, however the debt of $2,000 a month is just not distinctive for a full-time college pupil.

— Teresa L. Pardini, LMFT, Creativity in Counseling, Nipomo, Calif.

This younger lady acquired four.25 GPA & a full experience to Stanford regardless of by no means consuming ANYTHING in school so she would not should pee, bc that is what it takes for

youngsters to excel in an abled world. That she nonetheless has to struggle for care ought to infuriate you.https://t.co/B9vH1c1ATK

— Sonja Sharp (@sic_sonja) September three, 2019

— Sonja Sharp, Los Angeles

A Heroine In The Opioid Combat

Please thank this glorious, devoted and difficult lady (“Longtime Crusader Towards OxyContin Begins To See The Fruits Of Her Battle,” Sept. 17). That legal firm and each single member of the Sackler household had been nicely conscious of the whole rip-off for many years, however they saved their mouths shut, turned their heads, denied the whole lot and couldn’t care much less since they had been stuffing their particular person pockets with a whole lot of hundreds of thousands of for every member of that giant household. Each greenback must be clawed again from every member of the family. They’re laughing all the best way to the Sackler Wing of 20-plus museums round this planet.

— David Padawer, Pittsburgh

As the daddy of a recovering opioid addict I see Barbara’s efforts and keenness for accountability is so heroic. The lack of her son is so horrible….

— Dave (@dwpena) September 17, 2019

— Dave Pena, Roseville, Calif.

Senior Starvation And Pangs Of Conscience

I’ve been a medic for over 20 years. I’ve sufferers which have to choose between consuming or taking their drugs. It’s disgraceful. We have to have articles like this written day-after-day (“Ravenous Seniors: How America Fails To Feed Its Getting older,” Sept. three). Thanks.

— Eric Johnson, Marana, Ariz. 

Many hospital stays are for ppl w problems of hunger and malnutrition – confusion/delirium, harmful electrolyte imbalances in salt, sugar, potassium

We want packages for ravenous Individuals.

How America Fails To Feed Its Getting older https://t.co/gv6Z8HnqZH @khnews

— Tina Chee, MD, MPA (@Tina_Chee_MD) September three, 2019

— Dr. Tina Chee, New York Metropolis

I’m 68, a widower, disabled after two open-heart surgical procedures, with no household left. The final individual to go to me at dwelling was the yearly dwelling well being care nurse, again in February.

I’m identical to the folks in your article: outdated, worn-out and forgotten. After a lifetime of labor, I get by on a verify that’s half of what a minimum-wage employee flipping burgers would possibly make at $15 an hour. I can barely afford to eat the burgers now. Nobody, no insurance coverage firm, no politician is making an attempt to assist seniors out of poverty.

My greatest concern is dying and my little canine being left alone for weeks or months to die earlier than anybody finds me. Having moved to a rural space after my spouse died, folks don’t heat up quick to outsiders. It’s terrible to not converse to anybody for years — yep, years — outdoors of cashiers. Simply letting you already know there are plenty of us out right here.

— Rick Wrenn, Mount Carmel, Tenn.

What occurs when the system designed to guard hundreds of thousands of seniors dealing with hunger is damaged? The Older Individuals Act is one important piece holding many native Meals on Wheels packages collectively. We want you to ask… https://t.co/eicvq9gRln

— Chapa Arts & Photog. (@Berrysicles) September 12, 2019

— Maria De Jesus Chapa, Houston

Double Checking Truth-Examine Details

Because the chairman of Physicians for Honest Protection (PFC), I’ve joined medical doctors across the nation in working to guard sufferers from shock medical payments. I’m writing now to set the report straight on the implications of varied federal insurance policies below debate in Congress. Not solely did KHN’s latest article (“Medical doctors Argue Plans To Treatment Shock Medical Payments Will ‘Shred’ The Security Internet,” Aug. 7) overlook analysis from the American Journal of Managed Care, the Facilities for Illness Management and Prevention, and the Congressional Finances Workplace, it created a myopic interpretation of our argument in an effort to label it as “false,” which resulted in an inaccurate conclusion with respect to a fancy problem that deserves an intensive, data-driven and factual examination.

In accordance with the CBO, a benchmarking method would reduce funds to in-network physicians by as a lot as 20%. This interprets into tens of billions of shifted away from in-network physicians who aren’t sending shock payments over the following decade. Emergency physicians deal with all sufferers no matter their insurance coverage standing. In consequence, 70% of their sufferers are uninsured, seniors or poor households and kids. Subsequently, there isn’t a sensible distinction between decreasing business insurance coverage funds and decreasing Medicaid or Medicare charges. KHN’s personal earlier case research discovered that contributing components to hospital closures embody “excessive uninsured charges and a payer combine dominated by Medicare and Medicaid.” So, a benchmarking coverage would create even bigger disparities in high quality and entry to care over time for weak populations.

Others agree that business funds play a important position in supporting the care of America’s most weak sufferers, together with: American Academy of Orthopaedic Surgeons, American School of Emergency Physicians, American School of Radiology, America’s Important Hospitals, American Hospital Affiliation, American Medical Affiliation, Affiliation of American Medical Faculties, Catholic Well being Affiliation of the US, Kids’s Hospital Affiliation and Federation of American Hospitals.

As an alternative of talking with well being care consultants to higher perceive how reimbursement dynamics and affected person entry are inextricably linked in in the present day’s economic system, this text relied completely on the opinions of two biased analysis fellows who advocate for the very coverage that our advert opposes and whose statements are deceptive at greatest. The evaluation additionally disregards a quote from the California Medical Affiliation describing a scarcity of accessible anesthesiologists below California’s benchmarking method.

PFC’s mission is to guard sufferers from shock medical payments. That’s the reason, this yr alone, we helped drive constructive compromises that produced new legal guidelines in Texas, Colorado, Nevada and Washington. Equally, on the federal degree, we assist laws that makes use of a confirmed impartial dispute decision mannequin to guard sufferers with out disrupting accountable, in-network practices. To additional shield sufferers, it’s essential that Congress doesn’t create a fair bigger public well being problem with respect to the security internet whereas fixing the true problem of shock payments.

— Dr. Sherif Zaafran, Washington, D.C.

Once I traveled across the state final fall, Kansans made it clear that Medicaid enlargement is a excessive precedence. I will do the whole lot in my energy to make sure this would be the yr we’ll lastly increase Medicaid in Kansas. #RebuildingKansashttps://t.co/gg7BXeopMp

— Laura Kelly (@LauraKellyKS) September 6, 2019

— Gov. Laura Kelly, Topeka, Kan.

Contaminated With Advocacy

Your story about Medicaid enlargement fails to aim any severe description of the explanations for opposition to this enlargement (“How Political Maneuvering Derailed A Purple State’s Path To Medicaid Enlargement,” Sept. 6). The reader is left with the clear impression that opponents are ill-informed, parsimonious, uncaring of others (particularly the poor) or the entire above. There isn’t any suggestion that such opposing is likely to be in good religion. You actually can do higher than this. You insult the intelligence of your readers while you fail to ship the entire story in a good and evenhanded method to allow them to determine for themselves. There may be sufficient “us vs. them” in present media. Don’t drag it into well being care. If you wish to take positions on essential well being care points, please create an editorial web page; don’t infect your “information” with these positions. And no, I’m not a Republican. I’m an impartial uninterested in fixed advocacy within the media disguised as information. Thanks.

— Geoff Hargreaves-Heald, Lincoln, Mass.

Two (not surprising, perhaps disappointing) takeaways:– Citizen intent issues little if just a few state actors know work the system.– Nothing works higher than excessive medical payments for getting center class voters to empathize with Medicaid recipients.https://t.co/JxHaho26pU

— Juhyung Solar (@JuhyungSun) September 6, 2019

— Juhyung Solar, Tucson, Ariz.

Why Prescribed Weight Loss Is In poor health-Suggested

What the writer of the article dismissing the opinion of the dietitian who claimed stigma and yo-yo weight-reduction plan trigger extra hurt than weight problems itself failed to say is that, for many individuals, how weight would possibly contribute to the event of bodily sicknesses is immaterial (Weight problems Stigma And Yo-Yo Weight-reduction plan, Not BMI, Are Behind Persistent Well being Situations, Dietitian Claims, Sept. 17). The prescription to drop a few pounds, in and of itself, is damaging. Most dieters regain 100% or extra of weight misplaced inside 5 years. Moreover, people who find themselves informed to drop a few pounds and subsequently food plan are at considerably elevated threat for physique dissatisfaction, bingeing, disordered consuming and consuming problems.

Well being isn’t just bodily well being. Descartes invented mind-body dualism in a thought experiment within the 1600s. It’s an concept that permeates trendy tradition and drugs to today. Nonetheless, we’re not separate from our minds. Our psychological well being is just not separate from our “true” well being.

Weight problems could or could not trigger sickness. If the method of shedding pounds creates extra sickness within the type of disgrace and consuming problems in addition to well being care avoidance, then persevering with to blindly suggest it’s irresponsible. The advice to food plan must be made with an knowledgeable consent course of. “Being obese could put you liable to growing X, Y and Z. I’m recommending caloric restriction to treatment that. Caloric restriction is thought to be ineffective in the long run, and places you liable to growing an consuming dysfunction or of weighing greater than you do now. The choice to caloric restriction is to thoughtfully study obstacles to your entry of entire, nutritious meals, whether or not they be monetary, psychological or in any other case.

“Compassionately adopting a food plan that over time places extra colours in your plate and replaces processed meals with entire meals could in itself lead each to weight reduction and decreased threat of persistent medical circumstances. Moreover, discovering a approach to improve your bodily exercise, such that the exercise is related to pleasure and self-care, will even be protecting in opposition to persistent circumstances and will contribute to weight reduction. Nonetheless, if at any level weight reduction turns into the purpose somewhat than the logical consequence of sustainable modifications, then we’re again on the weight-reduction plan step, with all its consequent dangers.”

It doesn’t matter whether or not weight problems causes sickness. Intentionally shedding pounds is an ineffective method to addressing what could or will not be an issue, and moreover causes hurt. Allow us to information sufferers towards what they’ve management over: meals decisions and elevated exercise, and let go of the quantity, not as a result of it doesn’t affect well being, however as a result of specializing in it’s ineffective and counterproductive.

If a previously overweight individual is now skinny however depressing, hungry, obsessive, depressed and food-preoccupied as a result of that’s what we developed to do within the context of weight reduction, why is that higher? Any answer has to respect psychological and bodily well being outcomes, or it isn’t really a health-based advice.

— Dr. Sarah O’Neil, Boston

This text ignores the huge rising physique of proof round #weightstigma, argues in opposition to simply two items @chr1styharrison put ahead, then simply makes use of quotes from consultants to rebuff this declare and never proof and using an odd metaphor about carrots.

— Kerry (she/her) (@HAEScoach) September 18, 2019

— Kerry Beake, Mandurah, Australia

Summer season Camp Rehab — Or Torture?

The article “At This Summer season Camp, Struggling With A Incapacity Is The Level” (Aug. 13) portrays what you describe as “mandatory” however what many people adults with disabilities keep in mind as rehab torture — traumatic recollections of painful so-called remedy with questionable or no demonstrable outcomes. Even when this system had outcomes, many people would have chosen to not expertise the ache. It’s old-style rehab of pretending it isn’t torturous and “we all know what’s greatest for you.” This type of rehab was vehemently rejected by incapacity activists years in the past. It’s too dangerous adults who skilled this type of remedy weren’t consulted. I imagine few of them would describe this in constructive phrases. It’s not a brand new idea: In case you work exhausting, with ache, you possibly can turn into impartial! So if you happen to can handle to decorate your self in 4 hours and prepare for mattress in three hours, you’re impartial and met the targets set for you, regardless that you’re so drained you possibly can’t benefit from the remaining few hours of your day. Most adults with disabilities would set a purpose of getting a high quality of life over being impartial. This was a really biased story and may have been extra balanced from very totally different views, particularly from these with disabilities.

— RoAnne Chaney, government director of the Michigan Incapacity Rights Coalition, East Lansing, Mich.

SUMMER CAMP FOR KIDS WITH DISABILITIES! There must be extra camps identical to this one! This Nashville camp was began for teenagers who’ve disabilities that require bodily remedy, and the camp counselors flip the workouts into video games! https://t.co/F2uMFpSSLs

— D’Amore Harm Legislation (@DAmoreInjuryLaw) July 31, 2019

— Tom von Alten, Boise, Idaho

Prescribing A ‘Deep-Dive’ Into Hospital Excesses

I believe KHN Editor-in-Chief Elisabeth Rosenthal’s piece on hospital excesses is true on the mark (“Evaluation: How Your Beloved Hospital Helps To Drive Up Well being Care Prices,” Sept. 5). I used to be affiliated with a New York Metropolis hospital as a voluntary internist and retired 4 years in the past. I’m wondering if it will be doable to do a “deep dive” evaluation of a consultant hospital’s costs and expenditures (a number of New York hospitals come to thoughts as candidates) by an investigative reporting group. I think there may be some huge cash being spent that doesn’t improve affected person high quality of care (i.e., extreme numbers of directors getting egregious salaries). I believe you’ve mentioned the salient causes these contributing price components haven’t been extensively mentioned or debated ― however they have to be.

I keep in mind a information story a few affected person who purchased his synthetic hip implant within the U.S. wholesale and, to economize, took it with him to Belgium to have it inserted. The hospital regarded like a manufacturing facility, and he was reluctant to go in — however he did, and because it turned out the whole lot went nicely and he saved some huge cash!

― Dr. Lawson Moyer, New York Metropolis

from insurancepolicypro http://insurancepolicypro.com/?p=1457

[dinafbrownil]

Sickened By Billing Abuses, Readers And Tweeters Stand Up For Patients’ Rights

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Private Equity Predators?

First of all, let me thank you for writing about such an important issue (“Investors’ Deep-Pocket Push To Defend Surprise Medical Bills,” Sept. 11). I am going to tell you about my personal pain regarding surprising medical billing.

They can call themselves Doctor Patient Unity group or any other fancy name, but the reality is that they are all predators. I say this because I am the victim of these doctors groups. I work as a linguist with the U.S. Army and have top-secret clearance. I could lose my clearance if any of my bills go to a collections agency.

I had appendix surgery on Nov. 6, 2018, at the Davis Medical Center in Layton, Utah. The surgeon had told me that my surgery would take only 10 to 15 minutes. After two hours of surgery, I was released from the hospital and sent home. My insurer, CIGNA, paid all the Davis hospital bills and I paid my portion of the bills. Then in March 2019, I received two separate doctor’s bills totaling about $48,000. My insurance was not paying the doctor’s bills because they were out-of-network. The doctor’s office kept sending me letters to pay $48,000 from my pocket; if I did not pay, I was told, my bills would be sent to collections.

Finally, I received a letter from the collections agency saying that if I did not pay $26,770, it would send the information to the credit agencies. Can the Doctor Patient Unity group tell me what I should do? Should I lose my clearance and my job because I cannot afford to pay $26,770? Should I borrow money from the bank and then pay high interest to the bank for the rest of my life?

— Aziz Rehman, Kaysville, Utah

This is a very misleading article. Many independent physicians speaking out want IDR to solve the problem of outliers and take patients #OutOfTheMiddle. Insurance-backed lobbyists are using this issue as a #TrojanHorse to enrich corporate shareholders at expense of physicians.

— Amy Mecozzi Cho, MD MBA (@amychomd) September 12, 2019

On Twitter, Dr. Amy Mecozzi Cho of Minneapolis diagnosed holes in the article. For example, she told KHN, “the contracted rates for insurance are misleading since our bad debt for patients with high-deductible insurance is greater than 60% of their deductible, but insurance companies won’t bill them because they know this. And so our effective rates for commercial insurance are actually much lower than contracted. The medical loss ratio and the CBO estimates are not capturing these costs to patients and physicians.”

Religious Malpractice

My sister, a hospital chaplain (of Roman Catholic faith), informs me that it’s considered chaplain malpractice to try to force a patient to cope with suffering in the exact way others think they should (“Firing Doctor, Christian Hospital Sets Off National Challenge To Aid-In-Dying Laws,” Aug. 30). It would follow, then, that a hospital’s requiring staff to “help” patients “appreciate the Christian understanding of redemptive suffering” is a paternalistic dismissal of patient integrity and a form of malpractice. The medical relationship is between the patient and the doctor, not the patient and the Vatican.

— Gloria Kohut, Grand Rapids, Mich.

Many hospitals in India are controlled by religious organisations (Hindu, Jain, Christian, Muslim) Are they also as intolerant to differences in one's approach to what is ethical in medical practice as the Christian hospital in this case? https://t.co/Nzy6JN348B

— Amar Jesani (@amarjesani) September 8, 2019

— Amar Jesani, Mumbai, India

It’s unfathomable that students with disabilities can’t get the aid they need to attend college and live in the community! Bravo to this Stanford freshman for fighting for services. It’s past time for readily available help for students! #DisabilityRightshttps://t.co/EuVnUzEX8b

— Areva Martin, Esq. (@ArevaMartin) September 2, 2019

— Areva Martin, Los Angeles

Squeezing The Most Out Of Student Aid

I saw Jenny Gold’s excellent article in the Los Angeles Times about a disabled student’s need for assistance as she starts school at Stanford (“Spotlight: A Young Woman, A Wheelchair And The Fight To Take Her Place At Stanford,” Sept. 4). I wanted you to be aware that the Department of Rehabilitation in California pays for additional expenses for students to train them for future employment. This includes laptops, supplies, transportation expenses, necessary expenses. They might also pay for expenses for care above and beyond the approval of the state Department of Health Care Services.

All students face the issue of how to support themselves while in college. Stanford’s lovely gift of education for all who are accepted is often not used due to the high expenses of that area. Many students are unable to afford college, even with a full scholarship.

Those who have paid their way with student loans and are now employed in high service areas, such as medicine, psychiatry, social services and teaching, are strapped with lifetime payments. Our best and our brightest who serve our communities are in debt to the point where their income barely pays their lifetime of student loans. Sylvia Colt-Lacayo’s situation may have more expenses, but the debt of $2,000 a month is not unique for a full-time university student.

— Teresa L. Pardini, LMFT, Creativity in Counseling, Nipomo, Calif.

This young woman got 4.25 GPA & a full ride to Stanford despite never drinking ANYTHING at school so she wouldn't have to pee, bc that's what it takes for ♿ kids to excel in an abled world. That she still has to fight for care should infuriate you.https://t.co/B9vH1c1ATK

— Sonja Sharp (@sic_sonja) September 3, 2019

— Sonja Sharp, Los Angeles

A Heroine In The Opioid Fight

Please thank this wonderful, dedicated and tough woman (“Longtime Crusader Against OxyContin Begins To See The Fruits Of Her Struggle,” Sept. 17). That criminal company and every single member of the Sackler family had been well aware of the entire scam for decades, but they kept their mouths shut, turned their heads, denied everything and couldn’t care less since they were stuffing their individual pockets with hundreds of millions of dollars for each member of that large family. Every dollar should be clawed back from each family member. They’re laughing all the way to the Sackler Wing of 20-plus museums around this planet.

— David Padawer, Pittsburgh

As the father of a recovering opioid addict I see Barbara's efforts and passion for accountability is so heroic. The loss of her son is so terrible….

— Dave (@dwpena) September 17, 2019

— Dave Pena, Roseville, Calif.

Senior Hunger And Pangs Of Conscience

I’ve been a medic for over 20 years. I have patients that have to pick between eating or taking their medications. It’s disgraceful. We need to have articles like this written every day (“Starving Seniors: How America Fails To Feed Its Aging,” Sept. 3). Thank you.

— Eric Johnson, Marana, Ariz. 

Many hospital stays are for ppl w complications of starvation and malnutrition – confusion/delirium, dangerous electrolyte imbalances in salt, sugar, potassium

We need programs for starving People.

How America Fails To Feed Its Aging https://t.co/gv6Z8HnqZH @khnews

— Tina Chee, MD, MPA (@Tina_Chee_MD) September 3, 2019

— Dr. Tina Chee, New York City

I’m 68, a widower, disabled after two open-heart surgeries, with no family left. The last person to visit me at home was the yearly home health care nurse, back in February.

I am just like the people in your article: old, worn-out and forgotten. After a lifetime of work, I get by on a check that’s half of what a minimum-wage worker flipping burgers might make at $15 an hour. I can barely afford to eat the burgers now. No one, no insurance company, no politician is trying to help seniors out of poverty.

My biggest fear is dying and my little dogs being left alone for weeks or months to die before anyone finds me. Having moved to a rural area after my wife died, people don’t warm up fast to outsiders. It’s awful not to speak to anyone for years — yep, years — outside of cashiers. Just letting you know there are a lot of us out here.

— Rick Wrenn, Mount Carmel, Tenn.

What happens when the system designed to protect millions of seniors facing starvation is broken? The Older Americans Act is one critical piece holding many local Meals on Wheels programs together. We need you to ask… https://t.co/eicvq9gRln

— Chapa Arts & Photog. (@Berrysicles) September 12, 2019

— Maria De Jesus Chapa, Houston

Double Checking Fact-Check Facts

As the chairman of Physicians for Fair Coverage (PFC), I have joined doctors around the country in working to protect patients from surprise medical bills. I am writing now to set the record straight on the implications of various federal policies under debate in Congress. Not only did KHN’s recent article (“Doctors Argue Plans To Remedy Surprise Medical Bills Will ‘Shred’ The Safety Net,” Aug. 7) overlook research from the American Journal of Managed Care, the Centers for Disease Control and Prevention, and the Congressional Budget Office, it created a myopic interpretation of our argument in order to label it as “false,” which resulted in an inaccurate conclusion with respect to a complex issue that deserves a thorough, data-driven and factual examination.

According to the CBO, a benchmarking approach would cut payments to in-network physicians by as much as 20%. This translates into tens of billions of dollars shifted away from in-network physicians who are not sending surprise bills over the next decade. Emergency physicians treat all patients regardless of their insurance status. As a result, 70% of their patients are uninsured, seniors or poor families and children. Therefore, there is no practical difference between reducing commercial insurance payments and reducing Medicaid or Medicare rates. KHN’s own previous case study found that contributing factors to hospital closures include “high uninsured rates and a payer mix dominated by Medicare and Medicaid.” So, a benchmarking policy would create even larger disparities in quality and access to care over time for vulnerable populations.

Others agree that commercial payments play a critical role in supporting the care of America’s most vulnerable patients, including: American Academy of Orthopaedic Surgeons, American College of Emergency Physicians, American College of Radiology, America’s Essential Hospitals, American Hospital Association, American Medical Association, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association and Federation of American Hospitals.

Instead of speaking with health care experts to better understand how reimbursement dynamics and patient access are inextricably linked in today’s economy, this article relied exclusively on the opinions of two biased research fellows who advocate for the very policy that our ad opposes and whose statements are misleading at best. The assessment also disregards a quote from the California Medical Association describing a lack of available anesthesiologists under California’s benchmarking approach.

PFC’s mission is to protect patients from surprise medical bills. That is why, this year alone, we helped drive constructive compromises that produced new laws in Texas, Colorado, Nevada and Washington. Similarly, at the federal level, we support legislation that uses a proven independent dispute resolution model to protect patients without disrupting responsible, in-network practices. To further protect patients, it’s important that Congress does not create an even larger public health issue with respect to the safety net while fixing the real issue of surprise bills.

— Dr. Sherif Zaafran, Washington, D.C.

When I traveled around the state last fall, Kansans made it clear that Medicaid expansion is a high priority. I'm going to do everything in my power to ensure this will be the year we will finally expand Medicaid in Kansas. #RebuildingKansashttps://t.co/gg7BXeopMp

— Laura Kelly (@LauraKellyKS) September 6, 2019

— Gov. Laura Kelly, Topeka, Kan.

Infected With Advocacy

Your story about Medicaid expansion fails to attempt any serious description of the reasons for opposition to this expansion (“How Political Maneuvering Derailed A Red State’s Path To Medicaid Expansion,” Sept. 6). The reader is left with the clear impression that opponents are ill-informed, parsimonious, uncaring of others (especially the poor) or all of the above. There is no suggestion that such opposing might be in good faith. You really can do better than this. You insult the intelligence of your readers when you fail to deliver the whole story in a fair and evenhanded manner so they can decide for themselves. There is enough “us vs. them” in current media. Don’t drag it into health care. If you want to take positions on important health care issues, please create an editorial page; don’t infect your “news” with those positions. And no, I’m not a Republican. I’m an independent tired of constant advocacy in the media disguised as news. Thank you.

— Geoff Hargreaves-Heald, Lincoln, Mass.

Two (not shocking, maybe disappointing) takeaways: – Citizen intent matters little if a few state actors know how to work the system. – Nothing works better than high medical bills for getting middle class voters to empathize with Medicaid recipients.https://t.co/JxHaho26pU

— Juhyung Sun (@JuhyungSun) September 6, 2019

— Juhyung Sun, Tucson, Ariz.

Why Prescribed Weight Loss Is Ill-Advised

What the author of the article dismissing the opinion of the dietitian who claimed stigma and yo-yo dieting cause more harm than obesity itself failed to mention is that, for many people, how weight might contribute to the development of physical illnesses is immaterial (Obesity Stigma And Yo-Yo Dieting, Not BMI, Are Behind Chronic Health Conditions, Dietitian Claims, Sept. 17). The prescription to lose weight, in and of itself, is damaging. Most dieters regain 100% or more of weight lost within five years. Additionally, people who are told to lose weight and subsequently diet are at significantly increased risk for body dissatisfaction, bingeing, disordered eating and eating disorders.

Health is not just physical health. Descartes invented mind-body dualism in a thought experiment in the 1600s. It is an idea that permeates modern culture and medicine to this day. However, we are not separate from our minds. Our mental health is not separate from our “true” health.

Obesity may or may not cause illness. If the process of losing weight creates more illness in the form of shame and eating disorders as well as health care avoidance, then continuing to blindly recommend it is irresponsible. The recommendation to diet should be made with an informed consent process. “Being overweight may put you at risk of developing X, Y and Z. I am recommending caloric restriction to remedy that. Caloric restriction is known to be ineffective in the long term, and puts you at risk of developing an eating disorder or of weighing more than you do now. The alternative to caloric restriction is to thoughtfully examine obstacles to your access of whole, nutritious foods, whether they be financial, psychological or otherwise.

“Compassionately adopting a diet that over time puts more colors on your plate and replaces processed foods with whole foods may in itself lead both to weight loss and decreased risk of chronic medical conditions. Additionally, finding a way to increase your physical activity, such that the activity is associated with joy and self-care, will also be protective against chronic conditions and may contribute to weight loss. However, if at any point weight loss becomes the goal rather than the logical outcome of sustainable changes, then we are back at the dieting step, with all its consequent risks.”

It doesn’t matter whether obesity causes illness. Deliberately losing weight is an ineffective approach to addressing what may or may not be a problem, and additionally causes harm. Let us guide patients toward what they have control over: food choices and increased activity, and let go of the number, not because it doesn’t influence health, but because focusing on it is ineffective and counterproductive.

If a formerly obese person is now skinny but miserable, hungry, obsessive, depressed and food-preoccupied because that’s what we evolved to do in the context of weight loss, why is that better? Any solution has to respect mental and physical health outcomes, or it is not truly a health-based recommendation.

— Dr. Sarah O’Neil, Boston

This article ignores the massive growing body of evidence around #weightstigma, argues against just two pieces @chr1styharrison put forward, then just uses quotes from experts to rebuff this claim and not evidence and the use of an odd metaphor about carrots.

— Kerry (she/her) (@HAEScoach) September 18, 2019

— Kerry Beake, Mandurah, Australia

Summer Camp Rehab — Or Torture?

The article “At This Summer Camp, Struggling With A Disability Is The Point” (Aug. 13) portrays what you describe as “necessary” but what many of us adults with disabilities remember as rehab torture — traumatic memories of painful so-called therapy with questionable or no demonstrable results. Even if the program had results, many of us would have chosen not to experience the pain. It’s old-style rehab of pretending it isn’t torturous and “we know what’s best for you.” This sort of rehab was vehemently rejected by disability activists years ago. It’s too bad adults who experienced this kind of therapy weren’t consulted. I believe few of them would describe this in positive terms. It’s not a new concept: If you work hard, with pain, you can become independent! So if you can manage to dress yourself in four hours and get ready for bed in three hours, you’re independent and met the goals set for you, even though you’re so tired you can’t enjoy the remaining few hours of your day. Most adults with disabilities would set a goal of having a quality of life over being independent. This was a very biased story and should have been more balanced from very different perspectives, especially from those with disabilities.

— RoAnne Chaney, executive director of the Michigan Disability Rights Coalition, East Lansing, Mich.

SUMMER CAMP FOR KIDS WITH DISABILITIES! There should be more camps just like this one! This Nashville camp was started for kids who have disabilities that require physical therapy, and the camp counselors turn the exercises into games! https://t.co/F2uMFpSSLs

— D'Amore Injury Law (@DAmoreInjuryLaw) July 31, 2019

— Tom von Alten, Boise, Idaho

Prescribing A ‘Deep-Dive’ Into Hospital Excesses

I think KHN Editor-in-Chief Elisabeth Rosenthal’s piece on hospital excesses is right on the mark (“Analysis: How Your Beloved Hospital Helps To Drive Up Health Care Costs,” Sept. 5). I was affiliated with a New York City hospital as a voluntary internist and retired four years ago. I wonder if it would be possible to do a “deep dive” analysis of a representative hospital’s charges and expenditures (several New York hospitals come to mind as candidates) by an investigative reporting group. I suspect there is a lot of money being spent that does not enhance patient quality of care (i.e., excessive numbers of administrators getting egregious salaries). I think you’ve discussed the salient reasons these contributing cost factors have not been widely discussed or debated ― but they must be.

I remember a news story about a patient who bought his artificial hip implant in the U.S. wholesale and, to save money, took it with him to Belgium to have it inserted. The hospital looked like a factory, and he was reluctant to go in — but he did, and as it turned out everything went well and he saved a lot of money!

― Dr. Lawson Moyer, New York City

from Updates By Dina https://khn.org/news/september-letters-readers-and-tweeters-patient-rights/