As U.S. Sen. Ben Cardin, D-Md., toured Carroll County on Friday, the recent shooting of House Majority Whip Steve Scalise sat heavy on his mind and intertwined into most of his conversations.
"I know it's crazy times. This has been a very difficult week," Cardin said in a meeting with local government officials. "What happened this week was particularly hard for all of us."
Cardin said the members of both Congress and the Senate are in the business for democracy. And while they may disagree sometimes, that's a good thing — that's what real democracy is, he said.
They can't let what happened this past week to Scalise, a Republican, affect that commitment to democracy, he added. Both parties in the House and Senate need to continue to work together, he said.
As discussions included talk of the current state of the country's political system, Cardin delved into local issues in Carroll dealing with health care, the opioid crisis and the Trump administration's proposed budget's effect on local nonprofits.
In a morning panel discussion with LifeBridge President Neil Meltzer and Carroll Hospital President and CEO Leslie Simmons, Cardin first addressed the health care bill being constructed behind closed doors by the Republican Senate leadership — a process that he claimed has garnered bipartisan ire.
"It is not the way the process is supposed to work," Cardin said. "The Republicans are outraged about what their leadership is doing on health care, but they won't talk about it publicly."
Without anyone but the Republican leadership having yet seen the Senate health care bill, Cardin said he is forced to use the bill the House passed in May, the American Health Care Act, as a model, and that model could present problems for Marylanders.
The Congressional Budget Office, he said, estimates about 20 million people could lose their insurance coverage if the AHCA were to become law. In Maryland, it's estimated 160,000 people would lose private insurance under the law, and more than 200,000 would lose expanded Medicaid coverage.
Another apparent risk of a health care bill similar to the AHCA, Cardin said, could be reduced federal spending for reimbursing drug addiction treatment services in a local setting.
"Do you have deep enough pockets to make up for that?" he asked the audience of about 40 health care professionals. "I am told you do not."
None of those criticisms of Republican health care legislation meant that there were not also problems with the Affordable Care Act, Cardin said, noting there are always unintended problems with big legislation.
"There is an unintended problem particularly in the individual marketplace; there is not enough competition," he said, keeping costs high for consumers. At the same time, it turns out there are far more sick people, or people looking only for a short-term policy while between jobs, shopping in the marketplace than healthy people looking for a long-term insurer, which pinches insurers and drives up costs.
One possible solution for the marketplace would be to continue enforcing the individual mandate to purchase insurance, Cardin said in an interview after the event, and another would be further public education as its value.
"Third is you could make it more affordable and bring down the cost. You could do that by increasing the credits or deal with trying to look at where the cost centers are in the individual marketplace and trying to bring them down," he said. "You might sacrifice some coverage, but at least you are making it more competitive and therefore more attractive for younger people."
Despite his concerns about the existing Affordable Care Act and the still-shrouded Senate replacement bill, Cardin said he was optimistic there would eventually be a bipartisan legislative fix and that, for the sake of local health care organizations, it would be better to do it sooner rather than later.
"We do believe at the end of the day, Democrats and Republicans will have to come together to fix this health care system," he said. "When you try to plan your services here in Carroll County, and you don't know what the federal partnership will be year in and year out, it makes it extremely difficult."
That's a sentiment that really resonated with Simmons.
"The senator made a good point: It's hard to run an organization when you're not sure which way things are going to go," Simmons said after the event. "I can remember when we used to do strategic planning for seven to 10 years; now we are lucky to do it for two to three years. It's hard to project forward."
In a question-and-answer session, Cardin responded to inquiries about many aspects of the health care system, from tort reform, to getting Veterans Administration approval to treat veterans at Access Carroll in Westminster, to the question of transition to a single-payer health care system.
On torts, Cardin agreed that the cost of medical malpractice lawsuits is a major drag on the health care system and, worse, he does not believe the tort system is providing the remedies for unjustly injured patients either. He believes a bill encompassing both those aspects of tort reform could win bipartisan support among his Senate colleagues.
On getting approval to treat veterans in Carroll County, a question posed by longtime proponent state Del. Susan Krebs, R-District 5, Cardin answered, "I will do everything I can do help you on that."
And as for single-payer?
"The fast answer is yes, there is some merit to that," Cardin said, taking care to differentiate that in a single-payer model the government pays for all medical care, as it does for a portion of the population in Medicare, but does not provide that care like the United Kingdom through its National Health Service.
Cardin said he does believe health care to be a human right, and single-payer to be perhaps the best model to accomplish universal access to care. He also noted that there is a large administrative cost to private insurance. And American companies could become more competitive if they did not have to pay for health insurance — and if Congress can pass corporate tax reform and lower rates.
But Cardin stopped short of saying he would fully endorse a move toward a single-payer system immediately, noting the problems of the American health care system have to do with access and efficiency, but not with quality of care and innovation.
"I want to make sure we maintain quality," he said. "I don't want to put all our eggs in one basket."
One thing Maryland has that is unique is not a single-payer system, but an all-payer hospital reimbursement system — and that, Cardin said, is something that he hopes can be preserved in whatever health care legislation eventually comes to a vote on the senate floor.
"Maryland is the only state in the country where when you come into the hospital, they are going to get basically the same reimbursement regardless of who is paying the bill, whether it is private insurance or the government," he said.
It's not clear if an all-payer model will be baked into the Senate bill, but Cardin said there is wide support for it among his colleagues. Whether or not Maryland's program could survive a sudden drop in the number of insured, however, is still an open question.
"Would we be able to maintain that if there were a disruption in the relative number of insured?" Cardin asked? "I don't know. I think it is going to be difficult."
Town, county government officials talk opioid crisis
Amid Cardin's Carroll County tour, he met with both town and county government officials, and with Carroll Community College President Jim Ball. The group met for lunch at the college to discuss a number of topics, but spent most of the two hours honing in on addiction and the opioid crisis.
"These opioid deaths are really shocking," Cardin said. "It's [happening in] every community."
Funding addiction services has bipartisan support, he said.
"The good news here is that this is a national priority. There's a lot of interest in giving you additional resources to fight this," Cardin said.
Sykesville Mayor Ian Shaw spoke about work with the Carroll County State's Attorney's Office and Drug Prevention and Treatment Liaison Tim Weber's attempts to get immediate intervention and treatment right after an incident where law enforcement or medical personnel are called.
"That's when they're most likely to take that option," Shaw said.
Commissioner Dennis Frazier, R-District 3, echoed those thoughts, and voiced concern over the gap in time between when someone agrees to seek help, and how long it can take for them to get it because of waiting for insurance paperwork to go through.
"Twenty-eight day treatment is not enough," Frazier said.
Twenty-eight days is roughly the length of a standard inpatient treatment center.
Frazier also brought up the idea of trying to treat someone struggling with addiction the same as someone struggling with suicidal thoughts — hospitals should be able to commit someone who has overdosed on a 72-hour hold, just like they would for someone who is contemplating or has tried to commit suicide.
Using drugs as dangerous as heroin is a self-destructive behavior that can lead to death, Frazier said.
Cardin agreed with the idea of trying to keep people in the hospital and getting them treatment faster.
"You can't let the person leave" without getting them help, he said.
With the increase of fentanyl and other substances being used to cut heroin, a lot of innocent people will continue to die, he said. They need to find ways to get a person help while they're vulnerable.
Commissioner Doug Howard, R-District 5, added that trying to solve the drug problem needs to be a multipronged approach. There needs to be law enforcement, education and treatment. And they need to not be looking to incarcerate the drug users — they need to get them help, he said.
Cardin spoke about how the medical community used "sloppy" protocols when giving out opioid pain medications. These protocols created addiction to prescription pain medications and has led to the increase in heroin use, he said.
"We've been too careless in the need to deal with pain," Cardin said. "We're paying a heavy price for that."
Nonprofit leaders share concerns over proposed cuts
Cardin also met with leaders of many of the nonprofits in Carroll County, taking questions about funding for early education, mental health services, affordable housing and Meals on Wheels.
President Donald Trump's proposed budget is "frightening," Cardin said. It would make cuts to funding for needed programs, he said.
"We have some very serious challenges moving forward," Cardin said.
Cardin was asked about veterans' services, and small issues that are holding up trying to use the former U.S. Army Recruiting/Reserve Building on Malcolm Drive in Westminster, as a homeless shelter and service center for veterans in Carroll.
Cardin said he would do all he could to clear the technicalities in the way of making this a location for veterans' services, and that no veteran should be homeless.
Nonprofit leaders also voiced concerns over cuts to Medicaid and how that would affect people living with disabilities like those many of the nonprofits serve.
"What we know for sure," Cardin acknowledged, "[is] as the federal government withdraws its support, there will be less services."
While the state would theoretically fill the voids as the federal government pulls out, the state doesn't have the resources to do so, Cardin said. So what would happen is a significant decrease in services to especially vulnerable people.
The senator also answered questions in regard to mental health care for families, as well as early childhood education. On both fronts, he spoke about the importance of investing in people's health and in children.
"Every time we invest in children, the returns are incredible," Cardin said.
Making big cuts that affect these programs will hurt people, he said, and he's not for this type of "irresponsible budgeting."