Why One Health System Stopped Suing Its Patients

 Jolynn Mungenast spends her days looking for ways to help people pay their hospital bills.

Working out of a warehouse-like building in a scruffy corner of this former industrial town, Mungenast gently walks patients through health insurance options, financial aid, and payment plans. Most want to pay, said Mungenast, a financial counselor at Rochester Regional Health. Very often, they simply can't.

"They're scared. They're nervous. They're upset," said Mungenast, who on one recent call worked with an older patient to settle a $143 bill. "They do think 'I don't want this to affect my credit rating. I don't want you to come take my house.'"

At Rochester Regional Health, that won't happen. The nonprofit system in upstate New York is one of only a few nationally that bar all aggressive collection activities. Patients who don't pay won't be taken to court. Their wages won't be garnished. They won't end up with liens on their homes or be denied care. And unpaid bills won't sink their credit scores.

American hospital officials often insist that lawsuits and other aggressive collections, though unsavory, are necessary to protect health systems' finances and deter freeloading.

But at Rochester Regional, ditching these collection tactics hasn't hurt the bottom line, said Jennifer Eslinger, chief operating officer. The system has even been able to move staff out of its collections department as it spends less to go after patients who haven't paid.

Eslinger said there's been another benefit to the change: rebuilding trust with patients.

"We think and talk a lot and strategize a lot about where is the distrust in healthcare," she said. "We have to remove that as a barrier to meaningful healthcare. We have to get the trust with the populations that we serve so that they can get the care that they need."

'Folks Cannot Afford This'

Rochester Regional, a large health system serving a wide swath of communities along the south shore of Lake Ontario, is big, with more than $3 billion in annual revenue.

But in a place where once-mighty employers like Kodak and Xerox have withered, finances can be challenging. In 2022, Rochester Regional finished nearly $200 million in the red.

Patients have their own challenges. Unable to afford their bills, many ended up in collections, or even on the receiving end of lawsuits. "We would go to court," acknowledged Lisa Poworoznek, head of financial counseling at Rochester Regional.

Then, before the pandemic, hospital leaders looked more closely at why patients weren't paying.

The barriers became clear, Poworoznek said: confusing insurance plans, high deductibles, and inadequate savings. "There are so many different situations that patients have," she said. "It's really just not as simple as demanding payment and then filing legal action."

Nationally, nearly half of adults are unable to cover a $500 medical bill without going into debt, a 2022 KFF pollopens in a new tab or window found. At the same time, the average annual deductible for a single worker with job-based coverage now tops $1,500opens in a new tab or window.

Instead of chasing people who didn't pay -- a costly process that often yields meager returns -- Rochester Regional resolved to find ways to get patients to settle bills before collections started.

The health system undertook new efforts to enroll people in health insurance. New York has among the most robust safety-net systems in the country.

Rochester Regional also bolstered its financial assistance program, making it easier for low-income patients to access free or discounted care.

At many hospitals, applying for aid is complicated -- long applications that demand extensive information about patients' income and assets, including cars, retirement accounts, and property, KFF Health News has found. Patients applying for aid at Rochester Regional are asked to disclose only their income.

Finally, the health system looked for ways to get more people on payment plans so they could pay off big bills over a year or two. Importantly, the payment plans are interest-free.

That was a change. Rochester Regional, like some other major health systems across the country such as Atrium Health, used to rely on financing companiesopens in a new tab or window that charged interest, which could add thousands of dollars to patients' debts.

"Folks cannot afford this," Poworoznek said.

Ending 'Extraordinary Collection Actions'

Working more closely with patients on their bills allowed Rochester Regional to stop taking them to court.

The health system also stopped reporting people to credit bureaus, a practice many medical providers use that can depress consumers' credit scores, making it harder to rent an apartment, get a car loan, or even get a job.

In 2020, Rochester Regional adopted a written policy barring all aggressive collections by the system or its contracted collection agencies.

That put Rochester Regional in select company. A 2022 KFF Health News investigationopens in a new tab or window of billing practices at 528 hospitals around the country found just 19 that explicitly prohibit what are called extraordinary collection actions.

Among them are leading academic medical centers, including UCLA and Stanford University, but also community hospitals such as El Camino Hospital in California's Bay Area and St. Anthony Community Hospital outside New York City.

Also barring extraordinary collection actions: the University of Vermont Medical Center; Ochsner Health, a large New Orleans-based nonprofit; and UPMC, a mammoth system based in Pittsburgh. Like Rochester Regional, UPMC officials said they were able to scrap aggressive collections by developing better systems that allow patients to pay off their bills.

Elisabeth Benjamin, a vice president at the Community Service Society of New York, a nonprofit that has led efforts to restrict aggressive hospital collections, said there's no reason more hospitals shouldn't follow suit, particularly nonprofits that are expected to serve their communities in exchange for their tax-exempt status.

"The value is to promote health, to care about a population, to promote health equity," Benjamin said. "Suing people for medical debt or engaging in extraordinary collection actions is really anathema to all those values," she said. "Forget about your 'cancer-mobile' or your child vaccination clinic."

Rochester Regional's approach doesn't eliminate medical debt, which burdens an estimated 100 million peopleopens in a new tab or window in the U.S. And payment plans like those the system encourages can still mean big sacrifices for some families.

But Benjamin applauded Rochester Regional's ban on aggressive collections. "I give them big props," she said. "It never should have been allowed."

New laws in New Yorkopens in a new tab or window now prohibit all medical bills from being reported to credit bureaus and restrict other collection tactics, such as wage garnishments.

Many hospital finance officials nevertheless say they need the option to pursue patients who have the means to pay.

"Maybe it's on a very specific case where there is an issue with someone just not paying their bill," said Richard Gundling, a senior vice president at the Healthcare Financial Management Association, a trade group.

But at Rochester Regional's finance offices, officials say they almost never find patients who just refuse to pay. More often, the problem is the bills are simply too big.

"People just don't have $5,000 to pay off that bill," Poworoznek said.

On her calls with patients, Mungenast tries to reassure the patients on the other end of the line. "Put yourself in their shoes," she said. "How would it be if that was you receiving that?"

https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/110180

Many Patients With Chronic Kidney Disease Never Diagnosed

 Despite seeing a healthcare provider, nearly a third of individuals with chronic kidney disease (CKD) went undiagnosed, researchers uncovered.

Roughly 2.85 million patients with a qualifying hospital visit were identified with either clinical CKD or at risk for CKD. But of 1.4 million patients that met the clinical criteria for CKD, 31% were undiagnosed, Joel Topf, MD, medical director of St. Clair Nephrology Research in Detroit, and colleagues reported.

This represented 440,749 individuals who met Kidney Disease Improving Global Outcomes (KDIGO) clinical CKD criteriaopens in a new tab or window, involving at least two test results 3 or more months apart with an estimated glomerular filtration rate (eGFR) under 60 ml/min/1.73m² or urine albumin-to-creatinine ratio (UACR) over 30 mg/g, according to a poster at the National Kidney Foundationopens in a new tab or window (NKF) Spring Clinical meeting.

"Thinking about 440,000 people who are engaged in the medical system but are being failed by that system is upsetting. That's a lot of moms, dads, aunts, and other loved ones not getting the care they should," Topf told MedPage Today.

"This is not just unselected Americans, but people that are already engaged in the health system. These are people that are expecting and deserve quality care. These people should know what diseases they have," he continued, saying he was "disappointed" by this finding. "Our medical system is letting people down. The diagnosis of CKD can't be made in a single point of time, it requires longitudinal follow-up. It's right in the name, it's chronic. But what we found was that this 'chronicity' can be established by grabbing older data from a prior encounter."

"I personally assumed that these undiagnosed CKD were primarily in people that were not engaged in the medical system," Topf added. "But here we found people who were getting tested and seeing doctors and were still leaving visits with an unnecessarily incomplete view of their health."

These findings point to "an incredible amount of inefficiency where providers are building a patient's health database," he added, pointing out the database suggests the diagnosis, but then no one is closing the loop and giving it to the patient.

"These inefficiencies now matter more than ever because we have drugs and therapies that can slow the progression of CKD, but these therapies don't cure CKD. If they did, then getting started early wouldn't matter. But since the therapies only slow the progression, starting as early as possible is essential to prevent severe disease, dialysis, and transplantation," he said.

Most of the undiagnosed CKD patients had at least one comorbidity; hypertension was the most common (67%), followed by hyperlipidemia (46%), and diabetes (31%). Most patients with undiagnosed CKD had stage 3 (82%). Compared with CKD patients with a diagnosis, those who went undiagnosed were more often female (63% vs 45%) and white (78% vs 72%).

Undiagnosed patients also had a high frequency of healthcare involvement. Forty-three percent had at least one emergency department visit within the year, while 26% and 10% had a hospitalization and intensive care unit admission, respectively.

For these undiagnosed patients, there was an estimated total all-cause annual healthcare cost of $6.7 billion. In 2021, average annual all-cause healthcare cost was $15,196 per undiagnosed CKD individual, which increased with CKD stage:

• Stage 3: $14,403
• Stage 4: $19,136
• Stage 5: $21,081

For the study, researchers utilized the PINC AI Healthcare Databaseopens in a new tab or window representing data from over 1,200 hospitals. Adults with inpatient or outpatient visits from 2017 to 2021 and ≥1 serum creatinine with eGFR <60 mL/min/1.73m2 or UACR > 30 mg/g were included. Patients visiting hospitals without continuous data submissions, or those with a history of extracorporeal membrane oxygenation procedures or kidney transplant were excluded.

Of the 2.85 million patients included, half (1.42 million) were identified as being at-risk for CKD. These individuals had at least one test result with an eGFR under 60 ml/min/1.73m² or UACR over 30, but did not meet KDIGO criteria.

"These are people who have half a diagnosis of CKD," Topf pointed out. "Now perhaps that albuminuria was transient due to a fever or exercise, and maybe that GFR was spurious or was due to [acute kidney injury]. And I'm sure that accounts for some of that 1.4 million, but for the rest they actually have CKD and they are just waiting for the confirmatory follow up 3 months after the index study."

"I had never thought about this group and it is pretty stunning that it is so large," he said. "In the most recent CKD Guidelines from KDIGO, they recognize and talk about this group and actually recommend physicians consider treating them. Pretty interesting when you think about that especially given what a large fraction of the people we looked at fell into this bucket."

While these findings highlight there are quite a few patients "floating around without a diagnosis," Topf said he doesn't think this is something that individual doctors can solve, and instead needs to be tackled by policymakers and people with a more strategic view of the problem.

"When you find that a third of people meeting the criteria for CKD are not being diagnosed, this reflects system-wide failures and we need a systematic approach to gathering disparate data and pushing this to physicians. We can't have doctors going on an information scavenger hunt to make a diagnosis," he said. "The promise of electronic health records and artificial intelligence is to do this type of work for us, so doctors can spend time listening to and building trust with their patients."

Disclosures

The study was funded by AstraZeneca.

Topf and co-authors reported relationships with AstraZeneca and PINC AI Applied Sciences, Premier Inc.

Primary Source

National Kidney Foundation

Source Reference: opens in a new tab or windowTopf JM, et al "Uncovering the burden of undiagnosed chronic kidney disease (CKD) in U.S. healthcare systems" NKF 2024; Poster 307.

https://www.medpagetoday.com/meetingcoverage/nkf/110206

Lung Function Tests: End of Racial Adjustments Could Have Wide Impact

 The elimination of race adjustments in lung-function testing could affect millions of people in the U.S. as they lose or gain eligibility for jobs and benefits due to reclassification of their pulmonary health, a new longitudinal analysis finds.

If race-neutral equations were applied to everyone aged 6-79, the number of cases of nonobstructive ventilatory impairment alone may shoot up by 141% among Black people while falling 69% among white people, reported Arjun Manrai, PhD, of Harvard Medical School, and colleagues here at the international conference of the American Thoracic Society (ATS)opens in a new tab or window.

On the other hand, more 754,000 Blacks may become ineligible for firefighting jobs due to exposure to dust or fumes, while 1.27 million whites may gain eligibility. Annual disability payments on Black veterans may increase by more than $1 billion as they decrease by $500 million among white veterans.

Study results were simultaneously published in The New England Journal of Medicineopens in a new tab or window.

"There are profound clinical, financial, and occupational consequences to how race is used in lung-function equations," Manrai told MedPage Today. "We were surprised by how large the effects were with millions of clinical reclassifications and billions of dollars at stake."

In recent years, researchers have rethought the use of race-based adjustments in lung function tests, and both the ATS and European Respiratory Society (ERS) have discouraged their use, the study authors write.

"The decision to reconsider the use of race in lung function testing arose from a larger conversation about the use of race in clinical algorithms broadly," co-author James A. Diao, M.Phil., also of Harvard Medical School, told MedPage Today. "Race-based calibration made Asian and Black patients appear less sick and Hispanic and white patients appear more sick relative to a race-neutral approach."

Among other concerns, there's been worry that race-based adjustments would obscure underlying disease in racial minorities and present challenges when the patient's race does not fit one of the specified categories or when doctors incorrectly assume the patient's race.

It's not clear how many medical institutions have adopted race-neutral lung function tests.

The researchers estimate if racial categories are eliminated and everyone aged 6-79 was re-evaluated using new race-neutral criteria, various groups would be reclassified:

• 12.5 million people for ventilatory impairment status
• 8.16 million for medical impairment ratings
• 2.28 million for occupational eligibility
• 2.05 million for grading of chronic obstructive pulmonary disease
• 413,000 for military disability compensation

The researchers also found that race-based and race-neutral lung-function equations had "similar discriminative accuracy" in regard to factors such as healthcare utilization, new-onset disease, and death related to respiratory disease.

Moving forward, "we believe hospitals should standardize their interpretation of lung function with the current ATS/ERS recommendations, policymakers should continue to re-evaluate guidelines and thresholds in light of new data, and researchers should continue to seek out and operationalize more precise measures of lung function as we move away from crude heuristics like race," Manrai said.

In an accompanying commentaryopens in a new tab or window, Meredith McCormack, MD, and David A. Kaminsky, MD, of Johns Hopkins University School of Medicine in Baltimore, and University of Vermont Larner College of Medicine in Burlington, respectively, write that the study relies on data sets with "impressive breadth."

The findings "show the vulnerability of applying threshold lung-function values as stringent cutoff points," they write. "The findings also show how a relatively small proportionate change can have a large practical effect," such as a redistribution of $1.94 billion in annual VA disability compensation.

The commentary authors urge medical professionals to not just rely on lung function tests but instead "consider all aspects of the patient's presentation ... For too long, such determinations have relied on simple measures, such as forced expiratory volume, that are susceptible to differences in interpretation on the basis of patient-reported race. We need new approaches that apply equally to everyone to assess an individual person's functional capacity or ability to perform jobs and other activities."

The researchers studied data such as spirometry results from 369,077 participants in several U.S. and U.K. databases and projected changes in clinical, occupational, and financial outcomes if race-neutral lung function criteria were put into place.

Among other findings, authors reported that classifications of moderate-to-severe chronic obstructive pulmonary disease would grow by 428,000 among Black people but fall by 1.1 million among white people. And 638,000 Black adults may get increased payments for impairment-based compensation due to work-related exposures to dust or fumes.

The study authors note limitations including the fact that spirometry results don't independently determine clinical diagnoses. In addition, "reclassifications may also be overestimated owing to the inclusion of persons who would not be materially affected by reclassifications (e.g., disqualification from firefighting attributed to persons not considering the occupation)."

Disclosures

The National Heart, Lung, and Blood Institute and National Institute of Environmental Health Sciences funded the study.

Manrai disclosed grants to his institution from the National Heart, Lung, and Blood Institute and the National Institute of Environmental Health Sciences. Diao had no disclosures.

Kaminsky discloses consulting (Methapharm, Vitalograph), speaker fees (MGC Diagnostics), and royalties (UpToDate, Elsevier). McCormack had no disclosures.

Primary Source

The New England Journal of Medicine

Source Reference: opens in a new tab or windowDiao JA, et al "Implications of race adjustment in lung-function equations" N Engl J Med 2024; DOI: 10.1056/NEJMsa2311809.

Secondary Source

The New England Journal of Medicine

Source Reference: opens in a new tab or windowMcCormack M, Kaminsky DA "Beyond diagnostics -- removing race from lung-function test interpretation" N Engl J Med 2024; DOI: 10.1056/NEJMe2403770.

https://www.medpagetoday.com/meetingcoverage/ats/110208

Who pays for long-term care?

 People are confused and overestimate Medicare's role in paying for long-term care

We've embarked on a host of studies about long-term care. One component of that effort is to assess the public's understanding of how these costs are financed.

Surveys over the last 10 years indicate that people are confused; most think that Medicare plays a major role. In fact, Medicare doesn't cover any type of long-term care, whether in a nursing home, assisted living community or at home.

Medicare covers medical services - hospital care (Part A), physician care (Part B), and prescription drugs (Part D). It won't pay for a stay in a long-term-care center or the cost of custodial care, such as assistance with the activities of daily living like bathing, dressing, eating and using the bathroom - if that's the only care needed.

One potential source of confusion may be that Medicare will pay for short-term stays in a skilled nursing facility within 30 days of 3+ days in a hospital. However, over half of Medicare-covered skilled nursing facility stays are for 20 days or less, and over 90% for 60 days or less. Medicare also provides hospice care to individuals meeting a minimum level of need threshold. Since much of the care covered by Medicare is short term and associated with an acute event, no one should expect Medicare to cover their day-to-day long-term-care needs as they age.

In terms of long-term care, the major public player is Medicaid - a joint federal-state program - which covers about 20% of the nation's total care hours provided and pays a considerable portion of the nation's nursing-home bills. In order to qualify for Medicaid, however, retirees must have both a certain level of functional limitations and low levels of income and assets. Because the income and asset limits are so low, even with allowable exemptions, it can be hard for individuals to qualify for Medicaid when they initially develop care needs. However, over time, some of those with extensive needs spend down their assets and do end up qualifying. Therefore, Medicaid plays a bigger role than one would think at first glance.

A recent study projected expenditures for people ages 65 through death for users of paid care; this calculation showed that 42% of the total came from Medicaid and another 38% from out of pocket (see Figure 1). The small amount attributable to Medicare is mainly hospice care - not something conventionally considered as traditional long-term care. Private insurance pays for only a sliver since most people do not have long-term-care insurance.

It's important to note that our estimates show that paid long-term care covers only 36% of total hours of care provided; most comes from informal care provided primarily by family (see Figure 2).

All that said, in a recent survey KFF asked participants: "If you or a family member had a long-term illness or disability and had to go into a nursing home, how would the bill mainly be paid?" The responses for those 65+, which are shown in Figure 3, indicate that 45% of respondents believed that Medicare would cover the cost.

Clearly, we have not done a very good job explaining the need for long-term care, how it is currently provided (mostly by family), and how the formal care is financed.

https://www.morningstar.com/news/marketwatch/20240520113/who-pays-for-long-term-care

Goldman's Commentary On Consumer Health Ominous

 As we wrap up the first quarter earnings season and approach the midpoint of the year, a major theme emerging out of corporate America and Goldman analysts is the deteriorating financial health of low-income consumers. 

A team of Goldman analysts led by Kate McShane, CFA, published the latest low-income activity dashboard that shows monthly trends have been "mixed recently, noting tailwinds from lower gasoline prices and improved mobility along with headwinds from weaker credit metrics and slowing consumer confidence." 

Let's remind readers that Goldman's top consumer trader, Scott Feiler, recently told clients, "Our desk is getting bearish on consumer and our soft landing basket. We think it's the most vulnerable area of cyclicality, and cyclicals/defensives are priced very optimistically, and we are starting to see a defensive rotation." 

In recent weeks, Goldman analysts headed by Bonnie Herzog noted, "With >75% of the US consumer universe having reported Q1 results, we see indications that the US consumer is proving more stretched than previously anticipated as inflation combined with a bit of softening in the macro (lower payrolls & an uptick in unemployment in April), elevated gas prices & high interest rates continue to eat into spending power & consumer confidence." 

Last week, retail sales data for April missed average estimates. This shows that spending fatigue among the working poor has emerged. Many low-income folks have maxed out credit cards and drained savings to survive the era of failed Bidenomics.  

This year, faltering lower-income consumers is a major theme, and Goldamn's McShane's latest commentary on consumer companies shows just that. 

It's evident that the lower-income consumer is stretched, and persistent inflation, mainly due to President Biden's $1 trillion spending spree every 100 days, has decimated whatever is left of the middle class. Stagflation threats are elevated. 

https://www.zerohedge.com/markets/goldmans-commentary-consumer-health-ominous-one

Alarmed Democrats flee Biden’s ailing brand in battleground states

 Vulnerable Senate Democrats are distancing themselves from President Biden’s ailing brand after polls show him trailing former President Trump in several battleground states.

Democrats in tough races are breaking with Biden over border security, liquified natural gas exports, the Israel-Hamas war and tariffs on Chinese goods.

They’re staying competitive in the polls despite Biden’s low approval ratings and lagging position relative to Trump, but they are worried the president’s political brand will start weighing them down as Election Day nears.

“If you go out there and do a focus group, the focus groups all say, ‘He’s 200 years old. You got to be kidding me.’ And the worst part about it is for unaffiliated voters or people that haven’t made up their mind, they look at this and say: ‘You have to be kidding us. These are our choices?’ And they indict us for not taking it seriously,” said a Democratic senator who requested anonymity to discuss the alarm sparked by Biden’s weak poll numbers in battleground states.

Polls have shown that 40 percent of registered voters in battleground states were not too satisfied or not at all satisfied with the candidates in the presidential election.

The senator said Democratic colleagues “know this is a problem” but also realize it’s too late to do anything about it and that “this is the ticket we have to get behind and we have to win with this ticket.”

“We’ll see how much gravity we can defy,” the lawmaker said of senators in tough races who are polling better than Biden.

A second Democratic senator, when asked about Biden’s poll numbers, said the president’s age is a persistent concern among voters.

“Biden’s showing his age in ways weirdly more than Trump,” said the senator, who noted that Trump, 77, is only four years younger than Biden, 81.

“People keep saying, ‘Why didn’t he take a pass, he’s just so tired?’” the senator said of constituents who are baffled over Biden’s decision to run for a second term. “That is such a prevalent feeling.”

Biden sometimes appears to walk stiffly or with a shuffling gait, which Republican-aligned critics love to point out in social media posts.

The lawmaker also cited the high costs of basic goods and services as another political headwind facing Biden.

“People are shocked at the cost of a house and the cost of drugs,” said the senator, who pointed out a can of midgrade paint now costs $55 a gallon.

A New York Times/Siena College poll of 4,097 registered voters across six battleground states found Biden trailing Trump in Arizona, Georgia, Michigan, Nevada and Pennsylvania and tied with him in Wisconsin.

The same poll, however, showed Democratic Senate candidates leading their likely Republican opponents in four states — Arizona, Nevada, Pennsylvania and Wisconsin.

Rosen emphasizes her independence

Sen. Jacky Rosen (D-Nev.), who is narrowly leading Republican opponent Sam Brown, 40 percent to 38 percent, has sought to separate herself from Biden, who is losing to Trump by double digits in the Silver State.

She broke with Biden over his decision to withhold bombs from Israel to pressure Prime Minister Benjamin Netanyahu to call off an invasion of Rafah.

Rosen called for the White House to provide Israel with “the unconditional security assistance it needs to defend itself,” telling Jewish Insider “the administration should not do anything that undermines Israel’s ability to defeat Hamas.”

Asked about Biden’s 33 percent approval rating and other poor poll numbers in Nevada, Rosen emphasized her independence and record of working with Republicans.

“For the third year in a row, I’m in the top 10 most bipartisan senators out of all 100. I’m the top three most independent Democratic senators out of now 51, and in the top 10 most effective Democrats. So people in my state know me. They know what we’ve been doing for Nevada. We’re going to continue to let them know,” she said.

“Some of it I’ve agreed with the president, not afraid to stand up to him when it’s not right for Nevada,” she said of her work in Washington.

She downplayed Biden’s poll numbers as “just a snapshot in time.”

Casey splits on some issues

Sen. Bob Casey (D-Pa.), who is running for reelection in Pennsylvania, where Biden is polling behind Trump 36 percent to 40 percent in the New York Times/Siena College survey, has split with Biden on liquified natural gas (LNG) exports and holding up arms to Israel.

“There are numerous occasions where I don’t agree with administration policy. LNG is the most recent example as well as the decision [Biden] made about arms transfer to Israel,” he said.

“Polling across the board at this stage is of limited value,” he insisted.

Casey’s work to distance himself from Biden on key issues appears to be paying off. Polls show him currently leading hedge fund CEO and Republican candidate David McCormick 46 percent to 41 percent.

A majority of voters in Pennsylvania — 54 percent — said they trust Trump to do a better job of handling the economy, while 42 percent trust Biden more.

And more Pennsylvania voters — 47 percent — said they think Trump would better handle the conflict between Israelis and Palestinians than those who trust Biden more on that issue — 42 percent.

“I’ve got to work every day to earn every vote, and that’s true of every candidate. I think in the end the president will carry Pennsylvania, and I think I will too,” Casey said.

Montana and Ohio are tough states for Dems

Biden is a bigger political liability for the two most vulnerable Democratic incumbents running in Montana and Ohio, where Trump is ahead by big margins.

An Emerson College poll of 1,000 registered voters in Montana in March showed 56 percent preferred Trump and 35 percent backed Biden. A SurveyUSA poll of 549 likely Montana voters in February showed Trump leading Biden 51 percent to 29 percent.

Sen. Jon Tester (D-Mont.), who is running for reelection to a fourth term, said he’s running his own race and trusts his brand will play a lot better with Montana voters.

“Biden’s running his race, I’m running mine. I’ve got a good brand, people understand who I am, and we got to remind them who I am and what I’ve accomplished and what I intend to accomplish,” he said. “They really are separate races.”

Tester scored a major legislative victory in 2022 when he spearheaded the push to enact the PACT Act to expand health care eligibility for military veterans, over conservative Republican objections.  

The new law has helped more than 4 million veterans get free screenings for toxic exposures and provided more than $1.85 billion in benefits.

“As with every president that’s come down the pipe, we’ve worked with them and we’ve opposed them. And it’s been the same thing with this one, and we do what’s best for Montana and rural America,” Tester said.

Tester has clashed with the Biden administration on several high-profile issues recently, notably the breakdown in security at the southern border.

The Montana senator vented his displeasure over the situation at the border and with Defense Secretary Lloyd Austin and Homeland Security Secretary Alejandro Mayorkas.

He told Austin bluntly this month that what’s going on at the border is “not sustainable and it’s unacceptable.”

In a tense exchange last month, he told Mayorkas, “The administration needs to step up, you need to step up!”

Tester this month became the first Senate Democrat to co-sponsor the Laken Riley Act, legislation that has become a Republican rallying cry.

The bill, named after the 22-year-old nursing student whose alleged killer is a Venezuelan migrant, would require federal officials to apprehend and detain immigrants in the country illegally who commit crimes until they can be deported.

And Tester sponsored a resolution with Sen. Mike Rounds (R-S.D.) to overturn the Biden administration’s decision to lift a ban on beef imports from Paraguay. It passed the Senate 70-25.

Sen. Sherrod Brown (D-Ohio), who faces a serious headwind because of Biden’s unpopularity in his home state, said Tuesday that Biden didn’t go far enough to protect American workers from cheap Chinese imports.

“While tariffs are needed to level the playing field for American workers, they are not enough to stop a flood of Chinese-government-subsidized products on their own. That’s why the administration must ban Chinese electric vehicles and use every possible tool to stop China’s cheating,” Brown said.

Trump is leading Biden in Ohio by an average of 10 points in recent polls.

Brown broke with Biden in May of last year when he announced he would cosponsor legislation to extend the emergency COVID-19 health policy known as Title 42, which former President Trump invoked to keep migrants from entering the country.

“We need more resources at the border,” he told reporters. “That means everything from military people at the border, police at the border, inspectors at the border, mental health professionals at the border to deal with this situation. It’s troubling.”

GOP signals confidence

Republicans say efforts by Senate Democrats to flee Biden’s brand won’t save them in November.

“President Biden’s favorabilities are the lowest of any president in 70 years. It’s a big problem for the Democrats. They know it,” National Republican Senatorial Committee Chair Steve Daines (Mont.) said.

Senate Majority Leader Chuck Schumer (D-N.Y.) is counting on his vulnerable colleagues running ahead of Biden by running on his accomplishments while dodging his personal negatives.

“If you look at the same polls, No. 1, all of the four battleground states they tested, every one of our Democrats was ahead, and that’s because our Democrats are great candidates. Every week they are implementing the great work we did in 2022, 2021, 2023,” he said when asked about Biden trailing Trump in Arizona, Michigan, Nevada and Pennsylvania, all of which are Senate battlegrounds.

https://thehill.com/homenews/campaign/4671279-alarmed-democrats-flee-bidens-ailing-brand-in-battleground-states/

Rate Hawk Down

 By Benjamin Picton, senior macro strategist at Rabobank

Bonds sold off on Friday and the NASDAQ closed a smidgen lower. Both the S&P500 and the Dow Jones managed minor gains, with the Dow’s outperformance again suggesting that equities continue to trade on sensitivity to discount rates. Two-year yields rose 3bps on Friday while 10-year yields managed a gain of 4.7bps, bear-steepening the curve.

Brent crude is trading just a touch above Friday’s close of $83.98/bbl, despite news over the weekend that Iranian President Ebrahim Raisi is missing after a helicopter carrying both he and Foreign Minister Amirabdollahian crashed in mountainous terrain in the country’s north-west. Latest reports suggest that the wreckage has been spotted by search teams, but that no signs of life have yet been detected.

While there is no suggestion of foul play, it is certainly not ideal for senior Iranian political figures to be involved in helicopter accidents while tensions between Israel and Iran remain in a heightened state. The Economist has suggested that if Raisi has been killed it could set off a power struggle in Iran as he was a leading candidate to become the eventual successor for Supreme Leader Khameini. Nevertheless, the reaction in the energy complex suggests that traders remain untroubled by the news.

Shifting to interest rate world, the post-CPI jubilation had clearly begun to wane at the end of last week as a number of Fed speakers took turns watering down the proverbial punch bowl. Mester, Williams and Barkin all talked down the prospects for rate cuts, suggesting that possibly, maybe, it might be appropriate to cut rates before the end of the year. Or it might not.

Mester – one of the FOMC’s more hawkish members – will be stepping down at the end of June. She scores +1 on Bloomberg Economics’ hawk/dove spectrometer. Under the FOMC’s current composition, the Spectrometer sums to zero (neither hawkish nor dovish), which means that the incoming President of the Cleveland Fed – who will remain a voting member in 2024 and 2025 –has the potential to tip the Fed’s overall bias in either direction.

Meanwhile, Bowman (perhaps the FOMCs most hawkish member) said that progress on labour market re-balancing has slowed, the Fed is monitoring to see if policy is sufficiently restrictive, and she is willing to hike again if inflation rises.

We could forgive Fed speakers for couching tentative predictions of future rate cuts in caveats around the potential for inflation to rise again. Last week’s CPI – while welcome - was the first release in three months that didn’t surprise to the upside. After the Powell pivot late last year sparked frenzied speculation of the timing and quantum of rate cuts, it only seems wise to be a little more circumspect this time around when the data falls the Fed’s way.

Indeed, the Bloomberg commodities index is warning not to write inflation’s obituary just yet. It has been rallying since February and is now at its highest reading since October last year. Cocoa has pulled back substantially since its April highs, as have cotton, sugar and coffee, but these have been more than offset by recent runups in aluminium, nickel, copper, silver, iron ore, steel, orange juice concentrate, soybeans, wheat, beef, gold, natural gas and diesel, while the recent ban on enriched uranium imports from Russia could also add to price pressures in the nuclear fuels supply chain. Higher commodity prices are obviously unhelpful while core services inflation remains a problem.

Overall, it seems that we’re back to “waiting for more data” for the time being, but the May FOMC meeting minutes due out later this week will still be a key point of interest for markets.

The Reserve Bank of New Zealand will be another point of interest as it meets to set the official cash rate. No changes are expected from the prevailing 5.50%, but the scheduled release of the Monetary Policy Statement – which includes updated forecasts – will be important for the local market.

The RBNZ has established a reputation as something of a bellwether for global interest rate cycles. With the economy in recession and the labour market showing recent signs of rapid softening, it will be worth keeping an eye on whether the RBNZ flags the possibility of an earlier cut to the policy rate than their current mid-2025 guidance.

The minutes of the RBA’s May policy meeting are also due to be released this week and may provide a point of contrast. While the RBNZ has the luxury of a singular focus on inflation, the RBA must reconcile its price stability objective with a full-employment mandate. That probably goes some way toward explaining the absence of any hawkish tilt from the RBA in May, even as Q1 inflation and labour market data prior to the meeting had been surprising on the strong side.

As Leonard Nimoy once said “if you chase two rabbits, you will lose them both”.

https://www.zerohedge.com/markets/rate-hawk-down