Special Report: Death and politics roil a Georgia jail

FILE PHOTO: The Chatham County Jail sits at sunset in Savannah, Georgia, U.S., May 2, 2019. REUTERS/Shannon Stapleton

By Ned Parker, Jason Szep and Linda So

SAVANNAH, Ga. (Reuters) – In the summer of 2016, Georgia’s Chatham County hired jail monitor Steven Rosenberg with a mission: scrutinize the county jail’s healthcare services after a string of deaths.

In the previous 30 months, seven inmates had died at the Chatham County Detention Center, shaking public confidence. The last healthcare provider lost its contract in June 2016 after some of its own staff accused it of improper practices.

Chatham County sought a fresh start, signing a multiyear contract worth $7 million annually with a small Atlanta company, CorrectHealth LLC. The county wanted to know whether the new provider was taking the steps needed to prevent deaths.

But after several trips to the jail that summer through winter, Rosenberg’s team delivered four scathing reports. They described staff shortages, unclear health guidelines and failures to give inmates prescribed medications. Such failings, they warned, could trigger “potential loss of life.” Indeed, that September, six weeks before the second report was issued, an inmate strangled himself with a telephone cord. The death came after the monitors warned that the facility lacked written policies for suicidal inmates.

In late December, Rosenberg pressed CorrectHealth and Quick Rx, the jail’s pharmacy operator, to open their books for inspection; his firm was hired to assess the company’s compliance with the contract and tally penalties for shortcomings. Before the day was out, the county sheriff barred Rosenberg from the detention center.

Both companies were politically connected in Savannah. CorrectHealth, and its president’s wife had donated $5,000 to the election campaign of Chatham County Sheriff John Wilcher. CorrectHealth also had hired a state senator to run the jail’s dental clinic. And pharmacy operator Quick Rx was owned by a powerful member of the Georgia House of Representatives.

Rosenberg’s team was allowed back three weeks later, but the skirmish was the start of a standoff between the monitor on one side, and county and company on the other. Within a year, the county terminated the monitor’s contract, at the sheriff’s request, and waived $5 million in fines the monitor had recommended imposing on CorrectHealth. Wilcher rebuffed a plan to hire a new provider.

Instead, commissioners in June 2018 handed CorrectHealth a new three-year deal worth $22 million. During the bidding process, Reuters found, CorrectHealth shared inflated budget costs with its competitors, allowing it to make a cheaper offer.

FILE PHOTO: An inmate on suicide watch sits while prison officers talk to him at the Chatham County jail in Savannah, Georgia, February 21, 2019. REUTERS/Shannon Stapleton

FILE PHOTO: An inmate on suicide watch sits while prison officers talk to him at the Chatham County jail in Savannah, Georgia, February 21, 2019. REUTERS/Shannon Stapleton

The Chatham County Detention Center’s troubles offer a look into the challenges American communities face in holding accountable the private companies that have been entrusted with managing healthcare services at a growing number of jails and prisons. The failed reform effort in Savannah also speaks to the power of local politics, in a county where two state officials had a piece of the jail medical contract.

After the county terminated Rosenberg’s contract in October 2017, medical and guard staff shortages persisted and medicines continued to go missing. Six inmates have died – five by their own hands – since CorrectHeath took over three years ago.

Wilcher said in a February interview he was “happy” with CorrectHealth. He declined to answer all follow up questions and referred Reuters to the county attorney, who did not reply.

CorrectHealth did not respond to interview requests or questions sent in writing. Quick Rx told Reuters it won the work on merit, not politics.

The United States incarcerates more prisoners than any other wealthy democracy, and an increasing number of local jails, housing over 700,000 inmates, contract with for-profit healthcare companies. The companies offer local governments ways to control jail spending and manage a notoriously unhealthy population.

Yet the for-profit industry operates with little local or national oversight, monitored only if localities volunteer to seek review by non-government accrediting groups. Despite the Georgia jail’s continued problems with suicides, it received coveted accreditations from a national industry body for inmate medical and mental health care.

“Healthcare providers do what they want to do. There’s often nobody monitoring the contract,” said U.S. Justice Department consultant Steve Martin, a former Texas Corrections Department general counsel who has inspected some 500 prisons and jails.

FRIENDS IN HIGH PLACES

Carlo Musso, an emergency room doctor who founded CorrectHealth in 2000, has built an operation that now holds 41 contracts at jails across Georgia and Louisiana, with 2017 operating revenue of nearly $45 million. He is also a generous donor to politicians and sheriffs and a fundraising stalwart for the Georgia Sheriffs Association. Musso, his wife and companies donated $363,000 over a dozen years to Georgia politicians seeking state office, records show.

In Chatham County, Musso’s chance came in August 2015 when the jail’s healthcare contract opened for bidding. The relationship between the county and the jail’s previous medical provider, Corizon Health Inc, had deteriorated after a string of deaths, straining their ability to work together and ultimately leading to its loss of the contract. In a letter to the county, Corizon said it had been made a “scapegoat” for problems.

Musso promised sweeping change at the Chatham County Detention Center.

That November, the county sheriff at the time died of cancer, triggering a special election. Wilcher, a 40-year veteran of local law enforcement, won in March 2016. Pitching himself as a reformer, he vowed to “make the sheriff’s office great again.”

In June 2016, CorrectHealth won the deal, taking over the jail’s healthcare that August. The county viewed the new tender as a way to improve jail medical care. “The old contract really had no teeth in it,” said Roy Harris, the acting sheriff before Wilcher was elected.

The new contract set requirements for medical staffing and fines for failing to meet them. Intake screenings had to be completed within four hours or the company faced a $500 penalty per violation. Inmates had to receive medications within two hours of their prescription schedule; violations brought $100 fines per case.

As CorrectHealth won the job, Musso promised to retain the jail’s pharmacy firm, Quick Rx, owned by Ron Stephens, a titan of the state Republican Party and two-decade veteran of the Georgia House of Representatives.

Quick Rx had held the jail contract since the 1990s, but faced recent criticism. In 2014, jail medical staff said a pharmacy technician, not a licensed pharmacist, was taking prescription orders in violation of Georgia law, leading to medication errors. Quick Rx denied the allegation, saying it adheres to state laws.

Musso initially wanted to hire another drug supplier, not Stephens’ company, said Karen Cotton, a retired major in charge of jail operations in 2016 with first-hand knowledge of the negotiations. “It was a political thing. Musso had to back off,” she said.

Stephens said his company was hired because it provides “exceptional pharmacy services” at good rates. CorrectHealth did not respond to queries about the hiring.

Musso had also forged a partnership with another politician, State Senator Lester Jackson, a Democrat popular with Chatham’s black community, who had served on the Democratic National Committee from 2009 to 2012.

Jackson owned a dentistry practice, Atlantic Dental Associates, that worked with Musso across the state since 2014. Today, Atlantic runs dental services at 18 jails with CorrectHealth.

Atlantic landed the Chatham County jail’s $197,500 annual dental contract from CorrectHealth a few months before Jackson appeared in pamphlets for Sheriff Wilcher during the white Republican’s campaign for a full four-year term that November. The image of a smiling Jackson shaking the sheriff’s hand cut across racial and partisan lines in the largely Democratic county, which is 41% African-American. It was a blow to Wilcher’s rival, McArthur Holmes, a black Democrat.

“See how politics comes into this thing?” Holmes said in an interview.

Jackson said he did not formally endorse Wilcher, but considers him a friend and did not object to the use of his picture. Holmes never sought his endorsement, he added.

Wilcher won by 10 percentage points, emerging as a steadfast CorrectHealth defender.

THE MONITORS

In July 2016, the county hired Rosenberg’s firm, Community Oriented Correctional Health Services. Founded in 2006, the Oakland nonprofit has served as a consultant to local governments in New York, Florida, California, New Jersey and Washington, D.C., at times called to testify before Congress.

In Savannah, it would assess the jail’s medical operations. If CorrectHealth performed poorly, it would suggest fines. Rosenberg’s account is taken from his team’s confidential reports, which Reuters obtained through an open records request.

Almost immediately, he and CorrectHealth began clashing.

At the end of CorrectHealth’s first month at the jail – August 2016 – the monitors urged the company to craft policies for dealing with mentally ill inmates, and told the county the provider was struggling to hire registered nurses for inmate intake screenings.

Long-running challenges over staffing “have not been rectified by CorrectHealth,” the monitors reported.

Soon, CorrectHealth grappled with its first inmate suicide.

At 5:19 a.m. on September 30, Guy Leonard hanged himself with a telephone cord barely three hours after he was booked. On an intake form, the nurse wrote that Leonard said he had no plans to hurt himself and did not appear intoxicated, though he had been arrested on a charge of public drunkenness.

After the suicide, the nurse changed the original intake form to say Leonard looked intoxicated at booking. The sheriff’s department scolded the medical team in a letter, saying altered forms “will give the appearance of impropriety by CorrectHealth.” The sheriff also fired two guards over their failure to check Leonard’s cell in the hour before he died, while a third officer resigned.

The monitors returned in November and reported that “not all inmates” were getting a full physical and mental health assessment in their first 14 days – a standard recommended by the correctional industry’s medical accreditation body. The reason, the monitors reported, was “staffing shortages.”

They also reported a breakdown in the delivery of prescriptions. Medications ordered for inmates were sometimes missing; at times, an inmate would be listed for the same prescription twice. CorrectHealth told the monitor the Quick Rx records system did not synchronize with its own electronic records, leading to prescription mistakes.

Nearly three months later, the monitors reported that a guard told them nursing staff had falsely claimed inmates were refusing medications, “when they actually just did not have the medication to administer to the patient because it had not been received from the pharmacy.”

The questions over Quick Rx were a potential embarrassment for the sheriff. Quick Rx owner Stephens, the ranking Savannah Republican in Georgia’s state house, had supported Wilcher with a $1,000 campaign donation. Stephens said the two have been friends “for many years” and that he contributes to many local officials.

In February 2017, Rosenberg’s firm recommended $3 million in fines for CorrectHealth over its staffing failures and the late delivery of medicines. By June 2017, the monitors had raised their fine recommendation to $5.2 million.

SUICIDES, QUESTIONS

On March 11, 2017, Demilo Glover, jailed a week earlier after an arrest on a drunk driving charge, told a nurse his medications had been changed and he hallucinated that a little boy had appeared in his room holding a can of green beans, a department report said. The CorrectHealth team moved him to a rear infirmary cell. Throughout the night, he screamed. Earlier, Glover, who described himself as bipolar, told medical staff he had not taken his antipsychotic and antidepressant prescriptions for one to two days before his arrest and made bad decisions when not medicated.

The next morning, March 12, two guards collected his breakfast tray and asked Glover if he was OK. After they left, Glover knotted his bed sheet around his neck and slung it from a pipe. Minutes later, the guards returned to the cell, finding his corpse.

Twice in the months before the suicide, monitors warned that the infirmary’s cells were dangerous for suicidal inmates. When the monitors told Wilcher the infirmary did not have enough nurses, he bristled. The sheriff, they wrote, “does not want to hear about anything having to do with CorrectHealth.”

FILE PHOTO: Jerome Hill climbs the stairs at the Chatham County Detention Center shortly before his suicide in Savannah, Georgia, U.S. in this September 30, 2016 handout photo. Chatham County Detention Center/Handout via REUTERS

On April 3 of that year, Jerome Hill, 36, was arrested for allegedly threatening his girlfriend with a handgun.

Barely 90 minutes after being jailed, Hill said he wanted to kill himself, a department internal affairs report said. At 6:20 p.m. on April 7, guard Sharon Pinckney opened Hill’s cell in the mental health wing to take him for a shower. Hill raced up the stairs to the wing’s second floor and, ignoring her pleas, jumped from the walkway’s railing, landing head first. He died 18 days later, while in a coma at a hospital.

Pinckney told investigators “she did not understand why she was alone dealing with inmates on suicide watch and who had other mental issues.”

The internal affairs report into Hill’s death makes no mention of his meeting CorrectHealth’s psychiatrist in his four days at the jail.

SHERIFF PUSHES BACK

As the deaths mounted, the sheriff began pushing back against the monitor’s scrutiny. In a June 2017 email, an aide to the sheriff told Rosenberg’s team they didn’t need to visit the jail so often.

On August 24, 2017, Wilcher emailed the county manager he “WOULD LIKE TO GET THE COACH [monitors] GONE THANKS SHERIFF.” He contended they hadn’t offered “one piece of advice” on how to correct problems.

Within two months, Rosenberg’s contract was terminated. At the same time, Wilcher was advocating that CorrectHealth’s contract be extended.

As the sides negotiated new contract terms, CorrectHealth balked at the millions in pending fines. At this impasse, county administrators began negotiating with Virginia healthcare provider MHM Centurion. CorrectHealth quoted a contract price of $8.6 million, saying the county had pressed it to hire more staff. But then Centurion quoted the county budget price of $7.1 million, and won the job.

At a county commission meeting October 20, 2017, Wilcher chastised the county. “I am happy with the provider I got,” he said.

Commissioners rebuffed him, voting 6-3 for Centurion. The company was supposed to take over one week later. But suddenly, the sheriff announced he could not finish the background checks for Centurion’s medical staff in time.

Faced with uncertainty, Centurion walked away. In turn, commissioners approved CorrectHealth staying on through June 2018 – ahead of the awarding of a new three-year contract. Centurion declined to comment.

The county waived CorrectHealth’s fines. Just one county commissioner, Chester Ellis, objected. “I think that was a conflict of interest because of the campaign donation,” he told Reuters, citing Musso’s donations to Wilcher.

INFLATED NUMBERS

In April 2018, CorrectHealth bid on a new healthcare tender. Among three bidders, its proposal received the poorest score from a county screening committee, but offered the lowest bid. One reviewer wrote: “1/10 on suicide prevention. Very little detail; Not thorough.”

Wilcher continued to back the company.

Without debate, County Commission Chairman Al Scott called an up or down vote on keeping CorrectHealth in June 2018. The vote was 6-1 in favor, with Ellis dissenting. Scott told Reuters the jail was the sheriff’s jurisdiction, so he followed Wilcher’s suggestion.

During the bidding, Reuters found, the company had inflated the costs of providing medical care when the county requested numbers to provide rival bidders.

Musso told the county he spent just over $1 million on drug costs. However, a Reuters review of CorrectHealth’s invoices from Quick Rx shows the actual spending on drugs in 2017 was $280,000 less. The inflated number allowed Musso to offer a lower bid than competitors. Musso did not answer questions about the conflicting numbers.

As CorrectHealth won the contract renewal, Wilcher hired his own monitor to offer guidance on securing a coveted accreditation from the National Commission on Correctional Health Care, an industry body that provides voluntary health standards for jails and state prisons and offers its seal of approval.

“We are not interested in, nor have or will we engage in, ANY activities or work that can be perceived to discredit you, the County, or its contractors,” monitor Ken Ray wrote the sheriff in his proposal. Ray did not respond to interview requests.

That June, NCCHC accreditation teams toured the jail and, two months later, the group sent notice it was granting a preliminary accreditation for the detention center’s healthcare services. The NCCHC also said it was awarding the jail the group’s first-ever certification for mental health services. At the time of its visit, the group said, the jail had not had a suicide in 12 months.

That was true, but the letter omitted the subsequent death of inmate Mosheh Underwood, 24, who hung himself in his cell August 4, 2018.

Upset after a call with his lawyer, Underwood had asked for paper to cover his cell window so he could have privacy to use the bathroom. A guard provided it – despite previous warnings from Rosenberg’s team about letting inmates cover their windows.

An hour later, Underwood, who hanged himself, was found dead.

Jaime Shikmus, the NCCHC’s vice president, said the sheriff’s office was not required to disclose the suicide because it occurred after the surveyors visited.

In the 48 hours before the jail’s certifications were formally unveiled, the sheriff and county worried in internal documents that its standing would be in peril if the organization got a complete picture of its problems.

In one email, jail administrator Todd Freesemann, then the sheriff’s policy and accreditation supervisor, advised Wilcher that the jail “does not have adequate mental health professionals to deal with the volume of mental health requirements.” In another, the county’s attorney warned the sheriff that the lack of registered nurses “jeopardizes your accreditations.”

On February 14, 2019, the news was officially announced. The Chatham County jail had won full accreditation for its mental health and healthcare services, becoming the first local jail to win this honor.

Four months later, a fifth inmate killed himself on CorrectHealth’s watch. Guards and medical staff rushed to resuscitate the inmate, but when they tried to revive his heart with a defibrillator, the first device was broken and the second’s battery was uncharged, a jail report said.

Today, CorrectHealth continues to hold its $22 million contract.

(Additional reporting by Peter Eisler and Grant Smith. Editing by Ronnie Greene)

Trump doubles down on Obamacare fight, asks court to overturn law

FILE PHOTO - A sign on an insurance store advertises Obamacare in San Ysidro, San Diego, California, U.S., October 26, 2017. REUTERS/Mike Blake

(Reuters) – U.S. President Donald Trump’s administration has stepped up its attack on the Obamacare health care law, telling a federal appeals court it agrees with a Texas judge’s ruling that the law is unconstitutional and should be struck down.

The Justice Department in a two-sentence letter to the Court of Appeals for the Fifth Circuit filed on Monday said it backed the December ruling by U.S. District Judge Reed O’Connor in Fort Worth that found the Affordable Care Act violated the U.S. Constitution because it required people to buy health insurance.

O’Connor ruled on a lawsuit brought by a coalition of 20 Republican-led states including Texas, Alabama and Florida, that said a Trump-backed change to the U.S. tax code made the law unconstitutional.

The 2010 law, seen as the signature domestic achievement of Trump’s Democratic predecessor, Barack Obama, has been a flash point of American politics since it passed, with Republicans including Trump repeatedly attempting to overturn it.

Democrats made defending the law a powerful messaging tool in the run-up to the November elections when polls showed that eight in 10 Americans wanted to defend the law’s most popular benefits including protections for insurance coverage for people with preexisting conditions. The strategy paid off and Democrats won a broad 38-seat majority in the U.S. House of Representatives.

“The Department of Justice has determined that the district court’s judgment should be affirmed,” Assistant U.S. Attorney General Joseph Hunt and other federal officials wrote in the Monday letter. They said they would file a more extensive legal briefing later.

Obamacare survived a 2012 legal challenge at the Supreme Court when a majority of justices ruled the individual mandate aspect of the program was a tax that Congress had the authority to impose.

In December, O’Connor ruled that after Trump signed a $1.5 trillion tax bill passed by Congress last year that eliminated the penalties, the individual mandate could no longer be considered constitutional.

A group of 17 mostly Democratic-led states including California and New York on Monday argued that the law was constitutional.

“The individual plaintiffs do not have standing to challenge the resulting law because they suffer no legal harm from the existence of a provision that offers them a lawful choice between buying insurance or doing nothing,” they wrote in court papers.

About 11.8 million consumers nationwide enrolled in 2018 Obamacare exchange plans, according to the U.S. government’s Centers for Medicare and Medicaid Services.

About 11.8 million consumers nationwide enrolled in 2018 Obamacare exchange plans, according to the U.S. government’s Centers for Medicare and Medicaid Services.

(Reporting by Scott Malone in Boston; Editing by Bill Trott)

Health insurers, hospital operators fall as Obamacare ruled unconstitutional

FILE PHOTO: A sign on an insurance store advertises Obamacare in San Ysidro, San Diego, California, U.S., October 26, 2017. REUTERS/Mike Blake

(Reuters) – Shares of health insurers, hospitals, and healthcare companies fell in early trading on Monday, after a federal judge ruled the Affordable Care Act (ACA), also known as Obamacare, unconstitutional late last week.

The ACA, introduced by former U.S. President Barack Obama in 2010 to provide affordable healthcare to all Americans, mandates that all individuals have health insurance or pay a tax.

But on Friday, Texas District Judge Reed O’Connor agreed with a coalition of 20 states that a change in tax law last year eliminating a penalty for not having health insurance invalidated the entire Obamacare law.

Centene Corp fell 7.8 percent to $117.5, while Molina Healthcare slumped 10.1 percent to $118.4. The companies are among health insurers with exposure to ACA.

WellCare Health Plans and Anthem Inc declined 4.7 percent and 2.1 percent, respectively.

“While we are disappointed in the recent Northern District of Texas court’s ACA ruling, we recognize that this is a first step in what will be a lengthy appeals process,” Molina Healthcare said.

“Regardless, the ACA will remain in effect for 2019, and we are optimistic that it will remain in effect thereafter.”

Brokerage Evercore ISI said it expected no immediate impact from the ruling, calling it only a declaratory judgment and not an injunction.

Even in case of an eventual injunction, the defendants would certainly seek and most likely get a stay pending appeal, Evercore said.

Hospitals and healthcare services providers Community Health Systems, Tenet Healthcare Corp and HCA Healthcare Inc fell between 4 percent and 8 percent.

(Reporting by Manogna Maddipatla in Bengaluru)

‘Clear evidence of humanitarian need’ in North Korea: U.N. aid chief

North Korea's Minister of Health Jang Jun Sang meets with the United Nations Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator Mark Lowcork in Pyongyang, North Korea in this photo released July 11, 2018 by North Korea's Korean Central News Agency. KCNA via REUTERS 

By Josh Smith

SEOUL (Reuters) – There is “very clear evidence of humanitarian need” in North Korea, the top U.N. aid official has said during the first visit of its kind to the isolated country since 2011.

U.N. Humanitarian Chief Mark Lowcock arrived in the North Korean capital of Pyongyang on Monday.

He met Kim Yong Nam, the nominal head of state and president of the Presidium of the Supreme People’s Assembly, on Wednesday, the North’s state media said.

Lowcock posted a video online outlining his observations after traveling to several areas in the southwest of the country.

“One of the things we’ve seen is very clear evidence of humanitarian need here,” he said in the video, posted to his official Twitter account and the U.N. website.

“More than half the children in rural areas, including the places we’ve been, have no clean water, contaminated water sources.”

Although humanitarian supplies or operations are exempt under U.N. Security Council resolutions, U.N. officials have warned that international sanctions over North Korea’s nuclear weapons and ballistic missile programs are exacerbating humanitarian problems by slowing aid deliveries.

About 20 percent of children in North Korea suffer from malnutrition, highlighting the need for more funding for humanitarian aid, Lowcock said.

Access for humanitarian workers was improving, he said without elaborating, but he noted that funding was falling short.

The United Nations says it had to stop nutrition support for kindergartens in North Korea in November because of a lack of funds, and its “2018 Needs and Priorities Plan” for North Korea is 90 percent underfunded.

While visiting a hospital that is not supported by the United Nations, Lowcock said there were 140 tuberculosis patients but only enough drugs to treat 40 of them.

More than 10 million people, some 40 percent of the population of North Korea, need humanitarian assistance, the United Nations said in a statement.

Lowcock was also due to meet humanitarian agency representatives and people receiving assistance to get a better understanding of the humanitarian situation, the United Nations said.

(Reporting by Josh Smith; Editing by Robert Birsel)

U.S. to consider expanding Medicare drug price negotiation

By Yasmeen Abutaleb

WASHINGTON (Reuters) – The Trump administration is considering expanding Medicare’s ability to negotiate the cost of drugs by giving private payers a role in setting the price of medicines administered in hospitals and doctors’ offices, Health and Human Services Secretary Alex Azar said on Monday.

Azar’s comments provided more details on the plan announced on Friday by President Donald Trump to lower prescription drug costs for Americans.

While Trump has vowed to tackle rising prices since running for office, his plan spared the pharmaceutical industry from direct government negotiations to control costs. Drugmaker shares rose for a second day on Monday as Wall Street analysts said the new policies should not hurt industry profits.

Medicare is the national health insurance plan run by the federal government for Americans over the age of 65.

Azar said that Trump views tougher negotiation as key to the plan, and that his agency will consider an alternative system for buying Medicare Part B drugs, which are administered by a healthcare provider and covered directly by the government.

Instead, the administration would seek to allow private sector payers to negotiate the price of those medicines, as they do in Medicare Part D, which covers drugs that patients pick up at the pharmacy.

“We believe there are more private sector entities equipped to negotiate these better deals in Part B, and we want to let them do it,” Azar said in prepared remarks. “More broadly, the President has called for me to merge Medicare Part B into Part D, where negotiation has been so successful.

The S&P 500 healthcare index rose 1 percent on Monday, outpacing a 0.5 percent increase for the broader S&P 500.

(Additional reporting by Michael Erman; Editing by Michele Gershberg and Dan Grebler)

800 Venezuelans flee to Brazil daily to escape insecurity, hunger: UNHCR

Venezuelans line up to cross into Colombia at the border in Paraguachon, Colombia, Feb. 16, 2018. REUTERS/Jaime Saldarriaga/File Photo

GENEVA (Reuters) – More than 800 Venezuelans stream into northern Brazil each day, the United Nations said on Friday, citing Brazilian government statistics on people fleeing the worsening crisis in the economically crippled nation.

More than 52,000 Venezuelans have arrived in Brazil since the start of 2017, including an estimated 40,000 living in Boa Vista, capital of Roraima state, it said.

About 25,000 of the migrants are asylum seekers while 10,000 have obtained temporary resident visas and the rest are seeking to regularize their status, the U.N. High Commissioner for Refugees (UNHCR) said.

“We are stepping up our response in Brazil as the number of Venezuelan arrivals grows,” UNHCR spokesman William Spindler told a news briefing. “According to the government’s latest estimates, more than 800 Venezuelans are entering Brazil each day.”

Venezuelans have also fled to Colombia, Chile, Ecuador, Panama, Argentina and Peru, while others have sought refugee status in the United States, Spain, Mexico and Costa Rica, according to the UNHCR.

President Nicolas Maduro’s government in Caracas is faced with widespread discontent over hyperinflation and shortages of food and medicines during a fifth year of recession that he blames on Western hostility and the fall of oil prices.

Venezuelans report they are fleeing insecurity, violence and often a loss of income, Spindler said. Many are in desperate need of food, shelter and health care.

UNHCR is working with Brazilian authorities to register Venezuelans to ensure they have proper documentation that entitles them to work and access services, Spindler said.

Ten shelters have been opened in Boa Vista, each with 500 people, but some Venezuelans are living on the streets, he said.

Venezuelans willing to relocate from Roraima to other parts of Brazil are being flown to Sao Paulo and Cuiaba this week, as communities and services in Boa Vista are over-stretched, he said.

UNHCR’s $46 million appeal to help Venezuelans across the region is only 4 percent funded, Spindler said, and he called for more donations.

Within Venezuela, the economic crisis has limited people’s access to health services and medicines, World Health Organization spokesman Tarik Jasarevic said.

“WHO is working closely with the health authorities in order to fill those shortages. We are providing medicines for malaria and anti-retrovirals. We are equipping maternal hospitals with supplies that are needed for pregnant women and babies.”

Venezuela’s crisis has posed major challenges for governments in the region, who also worry that assistance to Venezuelans could increase the number of people leaving their country.

(Reporting by Stephanie Nebehay; Editing by Mark Heinrich)

Twenty states sue federal government, seeking end to Obamacare

FILE PHOTO: A sign on an insurance store advertises Obamacare in San Ysidro, San Diego, California, U.S., October 26, 2017. REUTERS/Mike Blake/File Photo

(Reuters) – A coalition of 20 U.S. states sued the federal government on Monday over Obamacare, claiming the law was no longer constitutional after the repeal last year of its requirement that people have health insurance or pay a fine.

Led by Texas Attorney General Ken Paxton and Wisconsin Attorney General Brad Schimel, the lawsuit said that without the individual mandate, which was eliminated as part of the Republican tax law signed by President Donald Trump in December, Obamacare was unlawful.

“The U.S. Supreme Court already admitted that an individual mandate without a tax penalty is unconstitutional,” Paxton said in a statement. “With no remaining legitimate basis for the law, it is time that Americans are finally free from the stranglehold of Obamacare, once and for all,” he said.

The U.S. Justice Department did not immediately respond to a request for comment on whether the Trump administration would defend the law in court.

The individual mandate in Obamacare was meant to ensure a viable health insurance market by forcing younger and healthier Americans to buy coverage.

Republicans have opposed the 2010 law formally known as the Affordable Care Act, the signature domestic policy achievement of Trump’s Democratic predecessor Barack Obama, since its inception.

Paxton and Schimel, both Republicans, were joined in the lawsuit by 18 states including Arizona, Florida, Georgia, Utah and West Virginia. It was filed in U.S. District Court in the Northern District of Texas.

(Reporting by Eric Beech in Washington)

Republicans’ push to roll back Obamacare faces crucial test

President Donald Trump (C) gathers with Vice President Mike Pence (R) and Congressional Republicans in the Rose Garden of the White House after the House of Representatives approved the American Healthcare Act, to repeal major parts of Obamacare and replace it with the Republican healthcare plan, May 4, 2017.

By Amanda Becker

WASHINGTON (Reuters) – A seven-year Republican effort to repeal and replace Obamacare faces a major test this week in the U.S. Senate, where lawmakers will decide whether to move forward and vote on a bill whose details and prospects are uncertain.

The Senate will decide as early as Tuesday whether to begin debating a healthcare bill. But it remained unclear over the weekend which version of the bill the senators would ultimately vote on.

President Donald Trump, after initially suggesting last week that he was fine with letting Obamacare collapse, has urged Republican senators to hash out a deal.

“Republicans have a last chance to do the right thing on Repeal & Replace after years of talking & campaigning on it,” Trump tweeted on Monday.

Republicans view former President Barack Obama’s signature 2010 health law, known as Obamacare, as a government intrusion in the healthcare market. They face pressure to make good on campaign promises to dismantle it.

But the party is divided between moderates, concerned that the Senate bill would eliminate insurance for millions of low-income Americans, and conservatives who want to see even deeper cuts to Obama’s Affordable Care Act.

The House in May passed its healthcare bill. Senate Republicans have considered two versions but have been unable to reach consensus after estimates showed they could lead to as many as 22 million fewer Americans being insured. A plan to repeal Obamacare without replacing it also ran aground.

If the Senate approves a motion to begin debating a healthcare bill, Majority Leader Mitch McConnell will determine which proposal has the most Republican support and move forward to a vote, Republicans said.

Republicans hold 52 of 100 Senate seats. McConnell can only afford to lose two Republican votes as Democrats are united in opposition.

Senator John Barrasso, a member of the Republican leadership, acknowledged on Sunday that there remained a lack of consensus among Republicans.

“Lots of members have different ideas on how it should be best amended to replace what is really a failing Obama healthcare plan,” Barrasso said on CBS’s “Face the Nation.”

The Republican effort has also been complicated by the absence of Senator John McCain, who has been diagnosed with brain cancer and is in his home state of Arizona weighing treatment options.

 

(Reporting By Amanda Becker; Additional reporting by Susan Heavey; Editing by Caren Bohan and Nick Zieminski)

 

Trump presses congressional Republicans to pass healthcare plan

By Susan Heavey and Susan Cornwell

WASHINGTON (Reuters) – President Donald Trump on Monday prodded the Republican-led U.S. Congress to pass major healthcare legislation but huge obstacles remained in the Senate as key lawmakers in his party voiced pessimism about the chances of rolling back the Obamacare law.

The House of Representatives approved its healthcare bill in May but the Senate’s version appeared to be in growing trouble as lawmakers returned to Washington from a week-long recess.

“I cannot imagine that Congress would dare to leave Washington without a beautiful new HealthCare bill fully approved and ready to go!” Trump wrote on Twitter, referring to the seven-year Republican quest to dismantle Democratic former President Barack Obama’s signature legislative achievement.

Trump appeared to be referring to the August recess that lawmakers typically take.

Senate Republican leaders have faced a revolt within their ranks, with moderate senators uneasy about the millions of Americans forecast to lose their medical insurance under the legislation and hard-line conservatives saying the bill leaves too much of Obamacare intact.

Republican Senator Pat Toomey said a new version of the legislation is expected to be released on Monday, telling the CNBC program “Squawk Box” that “there’s a shot” of getting to the 50 votes his party needs to win passage in the 100-seat Senate, with Vice President Mike Pence casting a tie-breaking vote.

Repealing and replacing the Affordable Care Act, dubbed Obamacare, was a central campaign pledge for Trump.

Obamacare expanded health insurance coverage to some 20 million people, with much of the increase due to an expansion of the Medicaid government health insurance program for the poor and disabled.

Republicans criticize the law as a costly government intrusion into the healthcare system while Democrats call the Republican legislation a giveaway to the rich that will hurt millions of the most vulnerable Americans.

“The Senate now is literally within weeks of being able to deliver on that promise to the American people,” Pence said in an interview with conservative radio host Laura Ingraham, adding there is “not yet agreement” in the Senate “but we are close.”

Some Republican lawmakers were more pessimistic, with Senator John McCain saying on Sunday the legislation is “probably going to be dead.”

Opponents of the legislation are expected to hold protests in Washington, organizing sit-ins at congressional offices, holding marches and stage vigils outside Republican senators’ homes. During last week’s recess, liberal groups organized town hall meetings and protests and ran advertisements criticizing the bill.

Senate Majority Leader Mitch McConnell faces the tricky task of crafting a bill that can attract Republican moderates and hard-line conservatives in a chamber his party controls with a slim 52-48 majority.

The Senate legislation would phase out the Medicaid expansion, drastically cut federal Medicaid spending beginning in 2025, repeal most of Obamacare’s taxes, end a penalty on Americans who do not obtain insurance and overhaul Obamacare’s subsidies to help people buy insurance with tax credits.

The nonpartisan Congressional Budget Office, which assesses the impact of legislation, has estimated 22 million people would lose health insurance over the next decade under the Senate bill.

Shares of U.S. hospital companies and health insurers, which have been particularly sensitive to developments involving the healthcare legislation, were mixed in midday trading on Monday.

Among hospital stocks, Tenet Healthcare Corp edged up 0.3 percent while HCA Healthcare Inc fell 0.5 percent.

Insurer Anthem Inc inched up 0.1 percent while Centene Corp, an insurer focused on Medicaid, was flat.

The broader S&P 500 healthcare sector was off 0.1 percent, underperforming a 0.2 percent gain for the overall S&P .SPX.

(For a graphic on who’s covered under Medicaid, click http://bit.ly/2u3O2Mu)

 

(Additional reporting by Doina Chiacu; Writing by Will Dunham; Editing by Tom Brown)

 

U.N. to need $8 billion this year to help Syrians at home and abroad

By Stephanie Nebehay

GENEVA (Reuters) – The United Nations said on Tuesday it will need a total of $8 billion this year to provide life-saving assistance to millions of Syrians inside their shattered homeland and to refugees and their host communities in neighboring countries.

The first part, a $4.63 billion appeal for 5 million Syrian refugees – 70 percent of whom are women and children – was launched at a Helsinki conference. Funds will be used to provide food, rent, education and health care.

A separate appeal for an estimated $3.4 billion to fund its humanitarian operation to help 13.5 million people inside Syria after nearly six years of war, is being finalised.

“The crisis in Syria remains one of most complex, volatile and violent in the world,” U.N. humanitarian chief Stephen O’Brien told a news conference.

Attempts to end the conflict in Syria have so far failed. After two-day talks, Iran, Russia and Turkey earlier announced a trilateral mechanism to observe and ensure full compliance with a ceasefire.

“Of course we fear that it will get worse,” O’Brien said. “And even if peace was to take place from tonight, the humanitarian needs within Syria would continue for a good time to come.”

Five countries – Lebanon, Turkey, Iraq, Jordan and Egypt – host nearly 5 million Syrian refugees, a “staggering number”, with few in camps, U.N. refugee chief Filippo Grandi said.

“Even if Syrians have stopped arriving in Europe in any significant numbers, I hope that everybody realizes that the Syria refugee crisis has not gone away and continues to affect millions in host communities and continues to be a tragic situation,” he said.

It was too early to say whether any solution would lead to further displacement or people returning to their homes.

“There is uncertainty surrounding the political process, we all hope that it will move in the right direction, but we can’t tell. We’ve had disappointments in the past,” Grandi said.

Providing livelihoods and restoring basic utilities are a priority in Syria, said Helen Clark, administrator of the U.N. Development Programme (UNDP).

“Even were there to be a political settlement tomorrow, we would still be here seeking support for humanitarian relief for a country that has been brought to its knees, with 85 percent living in poverty, 50 percent in unemployment and with the severe economic and social impacts on the neighborhood.”

(Reporting by Stephanie Nebehay; Editing by Tom Miles and Raissa Kasolowsky)