“These are the moments legislatively when you get creative. We’re getting creative.” (B)

“With Vice President Mike Pence casting a tie-breaking vote, Republicans moved forward on health care reform Tuesday as the Senate successfully passed a key motion to proceed to debate on repealing and possibly replacing Obamacare.
Momentum built over the course of the day as several previously skeptical members announced they would support Senate GOP leaders after they began detailing plans for more votes over the next days to shape the details of the legislation.
Sen. John McCain, who was recently diagnosed with brain cancer, returned to the Senate from Arizona to cast a key vote and Pence broke the tie after two Republicans — Sens. Susan Collins, R-Maine, and Lisa Murkowski, R-Alaska — and all the Democrats voted against it.
The vote was a key moment in the GOP’s seven-year campaign promise to repeal and replace the Affordable Care Act, but the final may fall short of that goal, and could well end up as a “skinny” repeal that disposes of just a few components of the law, known as Obamacare.” (A)

“Republican leaders Tuesday are trying to thread any needle they can to appease other holdouts.
“The only goal is to get onto the bill. Nothing happens until we do, so that’s the only goal,” a Republican aide said. “These are the moments legislatively when you get creative. We’re getting creative.”

Leadership was floating a strategy Tuesday morning that lays out a series of proposals that attempt to give everyone they want, even though nearly every element is destined for failure on the floor during the amendment process.
That strategy is as follows, in terms of amendment order:The full repeal bill that Paul backs.A bill including the “consumer freedom amendment” from that Sens. Ted Cruz and Mike Lee originally advocated for, that includes a request from Sen. Rob Portman for $100 billion in additional Medicaid funding. That would require 60 votes to pass.
The GOP bill proposed earlier this month that McConnell pulled when too many Republicans opposed it.Finally, a “skinnier” repeal bill that repeals Obamacare’s individual and employer mandates.” (B)

“Senate Republicans are considering passing a dramatically scaled-down version of their ObamaCare repeal bill as a way to pass something and set up negotiations with the House, according to GOP aides.
The measure, known as a “skinny bill,” is intended to be something all Republicans can agree on, so they can pass a bill and move to a conference committee with the House.
Aides say the scaled-down bill would likely just repeal ObamaCare’s individual and employer mandates and the medical device tax.
That would be a far narrower measure than the most recent Senate replacement bill, which also scaled down ObamaCare’s subsidies and cut Medicaid.
Experts warn, though, that repealing the individual mandate without any replacement measures would destabilize the insurance market and spike premiums. (C)


(A) Pence Breaks Tie, Senate Votes to Move Forward on Health Care Bill, by Leigh Ann Caldwell and Vaughn Hillyard, http://www.nbcnews.com/politics/congress/senate-sets-sights-skinny-repeal-obamacare-tuesday-s-voting-n786296
(B) By Lauren Fox, MJ Lee, Phil Mattingly and Ted Barrett, http://www.cnn.com/2017/07/25/politics/senate-health-care-vote/index.html
(C) Senate GOP floats scaled-down healthcare bill, by Peter Sullivan,http://thehill.com/policy/healthcare/343611-senate-gop-floats-scaled-down-healthcare-bill

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Rep. Blake Farenthold (R-Texas) suggested….that he’d like to duel with female senators he blames for the Senate’s failure to repeal and replace ObamaCare (A)


“Congress gives more care and consideration to bills renaming post offices than it has to legislation with staggering consequences for the health care system.” (B)

“After a strangely quiet weekend, this week Senate Republicans are scheduled to push through votes on a budget-reconciliation bill designed to repeal and/or replace Obamacare. There are at least six big questions that are hanging fire at the moment:
Can McConnell find a formula for a version of BCRA that snags 50 votes?
Will an ailing John McCain show up to save McConnell’s bacon?
Will Mitch McConnell go for broke on bringing up the bill even if he’s not sure he has the votes?
Where are Paul and other wavering senators on beginning debate?
Is a “straight repeal” of Obamacare truly doomed?
How will Republicans deal with potentially calamitous Senate parliamentarian’s rulings?” (C)

“Apparently short of votes even to begin that process, President Trump ratcheted up pressure for Republican senators to get on board, criticizing them for inaction and warning that they risked betraying seven years’ worth of promises to gut the health law and revamp it if they did not….”
“The remarks from Mr. Trump, who has been largely absent from the policy debate, had the ring of a threat by a president who has grown frustrated watching Republicans repeatedly try and fail to reach consensus on his promise to immediately roll back the health law and enact a better system. He said their constituents would exact a price for inaction — “you’ll see that at the voter booth, believe me” — and hinted that any Republican who did not support the bid to open debate on an as-yet-determined health bill would be painted as complicit in preserving a health law passed on the basis of “a big, fat, ugly lie.”” (D)

“Sen. Rand Paul, R-Kentucky, a holdout on the bill, said confusion reigns among lawmakers.
“We have no earthly idea what we will be voting on,” Paul said on Fox News Monday afternoon. “Last week they said we’re going to vote on a clean repeal. I said hooray, that’s what we promised. Now I’m told it may be the new Senate leadership bill, which is a big insurance bailout that I’m not for and doesn’t repeal Obamacare. So nobody has told us.”” (E)

(A) Senate Republicans Don’t Know What Health Care Bill They’re About To Vote For. That’s Nuts., by Jeffrey Young, http://www.huffingtonpost.com/entry/senate-republicans-dont-know-what-health-care-bill-theyre-about-to-vote-for-thats-nuts_us_59761b30e4b0e79ec19ae12b
(B) GOP lawmaker suggests duel with female senators, by Jacqueline Thomsen, http://thehill.com/business-a-lobbying/343477-gop-lawmaker-female-senators-are-responsible-for-healthcare-bill-failure
(C) Six Key Questions About the Senate Health-Care Bill As the Endgame Approaches, By Ed Kilgore, http://nymag.com/daily/intelligencer/2017/07/six-final-questions-about-the-senate-health-care-bill.html
(D) Senate Heads Toward a Health Care Showdown Vote Tuesday, by Thomas Kaplan and Julie Hirschfeld Davis, https://www.nytimes.com/2017/07/24/us/politics/senate-health-bill-obamacare-repeal-and-replace-trump-mcconnell.html
(E) Trump: Senate GOP needs to fulfill promise to end ‘Obamacare nightmare’, by Jeremy Diamond, MJ Lee and Lauren Fox, http://www.cnn.com/2017/07/24/politics/senate-trump-health-care-vote/index.html

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New York Daily News editorial: Senate Republican vote –“An embarrassment wrapped in cruelty wrapped in political disaster.” (E)


“I don’t know whether we’re proceeding to the House bill, a new version of the Senate bill, the old version of the Senate bill, the 2015 repeal-and-hope-that-we-come-up-with something-in-two-years bill. I truly don’t.” (Senator Collins) (A)

“Deductibles could become so high under the GOP plan, the CBO said, that many low-income people might decide not to purchase a health insurance plan, even if the premiums were low.
“Senate Republicans have run into another problem in passing their ObamaCare replacement bill: it could increase deductibles by thousands of dollars, potentially alienating moderates who are already skeptical of the bill.
An analysis released Thursday by the nonpartisan Congressional Budget Office concluded that a single policyholder purchasing a standard benchmark plan under the GOP bill could face a deductible of $13,000 in 2026.
Under current law, an individual making $56,800 would have a deductible of $5,000, while someone making $26,500 would have an $800 deductible. (B)

“Republican Senate leaders aim to hold a procedural vote as early as Tuesday to take up legislation to repeal or replace Obamacare, but it remained unclear which version of the bill senators would vote on…
Senator John Thune, a member of the Republican leadership, told “Fox News Sunday” the initial vote was simply a way to open debate on the bill so that senators from both parties could offer amendments.
“The first vote, which will occur sometime this week, will be to proceed to the consideration of that legislation and to at least have a debate where we can have an open amendment process,” Thune said.” (C)

“Sen. John Barrasso (R-Wyo.) said Sunday that the Senate will vote this week on a motion to proceed on a healthcare bill passed by the House of Representatives.
During an appearance on CBS’s “Face the Nation,” host John Dickerson asked Barrasso which legislation the upper chamber will come up for a vote.
“Well, it’s a vote, a motion to proceed to the bill that passed the House,” Barrasso said.
“That then comes to the Senate, and then we can vote, once we get on that bill, to amend it in various ways. And lots of members have different ideas on how it should be best amended to replace what is really a failing Obama healthcare plan.” (D)

New York Daily News editorial
“Enough already. Just stop. The Senate needs to call it quits on ever more pathetic attempts to slay the beast they call Obamacare, for the love of the 22 million or more Americans doomed to end up without coverage and insurance markets now dizzied with uncertainty…..
A replacement bill would, even in its second, supposedly kinder iteration, roll back Medicaid expansion that has enabled workers with low wages to afford decent coverage, and slash subsidies that make health insurance affordable for the working class. A cap on Medicaid, which has covered the poor for decades, would gut the program’s power to grow with the population…
An embarrassment wrapped in cruelty wrapped in political disaster.” (E)

(A) Obamacare vote nears with key details still missing, by Noam N. Levey, http://www.latimes.com/politics/la-na-pol-senate-obamacare-chaos-20170721-story.html
(B) GOP wrestles with soaring deductibles in healthcare bill, by Jessie Hellmann, http://thehill.com/policy/healthcare/343220-gop-wrestles-with-soaring-deductibles-in-healthcare-bill
(C) Republican strategy on healthcare bill in flux ahead of vote, Amanda Becker, https://www.reuters.com/article/us-usa-healthcare-idUSKBN1A80QG
(D) Top Republican: Senate will vote to proceed to House healthcare bill, by Mallory Shelbourne , http://thehill.com/homenews/senate/343372-top-republican-senate-will-vote-to-proceed-to-house-healthcare-bill
(E) The Senate’s sickness: A compulsion to keep trying a failed health care bill, http://www.nydailynews.com/opinion/senate-health-care-sickness-article-1.3346010

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“….. the parliamentarian has taken an already very difficult process for enacting health care legislation in the Senate and made it nearly impossible….”

“The official rules keeper in the Senate Friday tossed a bucket of cold water on the Senate Republican health bill by advising that major parts of the bill cannot be passed with a simple majority, but rather would require 60 votes. Republicans hold only 52 seats in the Senate.
Senate Parliamentarian Elizabeth MacDonough said that a super-majority is needed for the temporary defunding of Planned Parenthood, abortion coverage restrictions to health plans purchased with tax credits and the requirement that people with breaks in coverage wait six months before they can purchase new plans.
The Senate is using a budget process called “reconciliation” that allows Republicans to pass a bill with only 50 votes (and the potential tie to be broken by Vice President Mike Pence). But there are strict rules about what can and cannot be included, and those rules are enforced by the parliamentarian. Those rules can be waived, but that requires 60 votes, and all the chamber’s Democrats have vowed to fight every version of the bill to “repeal and replace” the Affordable Care Act, which is set for a possible vote next week.” (A)

“In a blow to the insurance industry, the parliamentarian has advised that two key market stabilization provisions in the bill would be against the rules. First, the legislation can’t appropriate the cost-sharing reduction subsidies insurers rely on to keep premiums and deductibles low; it can only repeal them.
Additionally, a “lockout” provision requiring consumers with a break in coverage to wait six months before buying insurance also violates the rules, according to the guidance.”
“The parliamentarian has also not yet ruled on a controversial amendment from Sen. Ted Cruz (R-Texas) that would allow insurers to sell plans that do not meet ObamaCare regulations. If that provision were struck, conservative support for the bill would be in doubt.”…
“The result is that the arcane rules of the Senate could end up making the bill harder for Senate Majority Leader Mitch McConnell (R-Ky.) to pass.” (B)

“In general, the parliamentarian has taken an already very difficult process for enacting health care legislation in the Senate and made it nearly impossible—unless Mitch McConnell is willing to blow up every Senate precedent without even knowing if it would be enough to persuade 50 senators from his own party. It will be a painful weekend for those whose dreams involve the repeal or replacement of Obamacare.” (C)

(A) Senate Parliamentarian Upends GOP Hopes For Health Bill, by Julie Rovner, http://khn.org/news/ruling-by-senate-parliamentarian-upends-gop-hopes-for-health-care-bill/
(B) Parliamentarian deals setback to GOP repeal bill, by Nathaniel Weixel, http://thehill.com/policy/healthcare/343234-parliamentarian-deals-setback-to-gop-healthcare-bill
(C) Senate Parliamentarian May Have Dealt the Last, No-Kidding-Final, Blow To Trumpcare, by Ed Kilgore, http://nymag.com/daily/intelligencer/2017/07/parliamentarian-deals-potentially-terminal-blow-to-trumpcare.html

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“McConnell is still planning votes on health-care legislation next week. But many things have to go right for his strategy to succeed, and not all of them are within his control.”

As we head towards next week’s vote, you might take a look at an excellent New York Magazine analysis.
Here Is Where Things Stand With the Senate Health-Care Bill , by Ed Kilgore, highlight and click on http://nymag.com/daily/intelligencer/2017/07/where-things-stand-with-the-senate-health-care-bill.html

“Getting Senate moderates to vote for a bill with a Medicaid per capita cap and the Cruz amendment is where the whole process has ground to a halt. But it seems the strategy is for McConnell to throw absolutely every nickel of funding at his disposal (somewhere in the neighborhood of $200 billion in “excess” deficit reduction, according to the latest Congressional Budget Office’s assessment of the revised BCRA) at the states to ease immediate coverage concerns caused by the rest of the bill.
But there is an existential threat to this scheme that could emerge as early as today, when the Senate parliamentarian informally lets senators know of her rulings as to whether various provisions of the pending bill (and various likely amendments) pass muster under budget rules requiring that all items are germane to federal spending and revenue levels. According to a handful of experts assembled by the Times, there is a decent chance the parliamentarian will deem the Cruz amendment unallowable. If so, that would leave McConnell with the unsavory choice of finding some way to regain conservative support for yet another revision of BCRA or, worse yet, overturning the parliamentarian’s ruling on the Senate floor. This latter contingency would, many fear, lead to a de facto abolition of the legislative filibuster, since a simple majority could at any time rule any provision germane to a budget bill, which cannot be filibustered.”

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“The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith.”

“A new official analysis released Wednesday finds that repealing much of Obamacare without a replacement law would increase the number of people without health insurance by 32 million people, double insurance premiums in the individual plan market and leave most of the United States without an insurer selling such plans by 2026.
The report comes as Republican leaders in the Senate, desperate to pass some kind of health-care law, have said that next week they might consider a possible Obamacare repeal bill that could eventually be amended to include a replacement.
The Congressional Budget Office estimated Wednesday that with a repeal-but-no replacement bill the number of uninsured is expected to be 17 million higher than if Obamacare remains in place. And by 2020 there would be 20 million more uninsured people, CBO said. That tally would grow to 32 million by 2026, the report said.” (A)

“President Trump did not do much to sell the Senate health care bill before its failure. But he gave the sale a shot Wednesday in the White House before cameras and a captive audience of nearly all the Republican senators. His comments were at times confusing, and in some cases, outright incorrect.
It shows the challenge for a president who doesn’t dive deeply into policy to sell his agenda.” (B)
To look at everything Trump said, with some fact checks and context: highlight and click on http://www.npr.org/2017/07/20/538171317/fact-check-trumps-confusing-remarks-to-senate-republicans-on-health-care

“….Trump claimed at the lunch that “we’re very close” to passing a repeal-and-replace bill. It was the latest sign of the disconnect between the president and the Senate. It also came a day after Trump tweeted “let ObamaCare fail” — and two days after he called for a repeal-only bill.” (C)

“Majority Leader Mitch McConnell spurred Republican senators Thursday to resolve internal disputes that have pushed their marquee health care bill to the brink of oblivion. Yet the GOP’s reeling effort to dismantle much of President Barack Obama’s health care law may face even longer odds because of Sen. John McCain’s jarring diagnosis of brain cancer.
“Dealing with this issue is what’s right for the country,” McConnell, R-Ky., said. He added, “It was certainly never going to be easy, but we’ve come a long way and I look forward to continuing our work together to finally bring relief.”
Nursing a slender 52-48 majority, McConnell has been unable to muster the 50 votes he’d need to approve his party’s health care overhaul. Vice President Mike Pence would cast the tie-breaking vote….
Aiming to finally resolve the issue, McConnell has said he’ll force a vote on the legislation early next week….” (D)

“If Collins is a no vote on any form of the legislation and Paul won’t support a replacement, and Capito and Murkowski won’t support the repeal-only approach, and Lee and Moran won’t support the replacement, and it’s unclear if McCain will be back next week … Republicans simply don’t have the votes throughout all the confusing scenarios. And that’s to say nothing of Dean Heller (R-Nev.), who has been cagey all along on any form of the legislation.” (E)

“The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith. It punishes the cautious senators who recoiled from huge Medicaid cuts by thrusting upon them a clear alternate they would prefer to evade. It intensifies mutual suspicion and ill-feeling inside a caucus where two senators—Nevada’s Dean Heller and Arizona’s Jeff Flake—have been explicitly threatened by the president and head of party.” (F)

“Under the humane approach, with a stronger health care system a shared goal, Republicans and Democrats would work together to fix the marketplace problems and restore confidence among insurance companies. In counties with no insurers, Congress could require the Federal Employees Health Benefits Program to offer coverage. State governments, working with the Trump administration, could create reinsurance programs to reduce the risk that insurers would lose money because of a few very sick patients. This could lower premiums and encourage insurers to operate in sparsely populated parts of the country.
If it chooses to set partisan point-scoring aside, the Trump administration would continue subsidy payments to insurers, House Republicans would drop their lawsuit and, going forward, Congress would appropriate money for these payments so that they could not be used to undermine the health care law. Quick action is needed on all fronts because insurers and state and federal regulators must finalize rates and policies for next year in the coming weeks. (G)

(A) CBO: Obamacare repeal bill would raise number of uninsured by 32 million by 2026, by Christine Wang and Dan Mangan, http://www.cnbc.com/2017/07/19/cbo-obamacare-repeal-bill-would-raise-number-of-uninsured-by-27-million-by-2020.html
(B) Fact Check: Trump’s Confusing Remarks To Senate Republicans On Health Care, by Danielle Kurtzleben, http://www.npr.org/2017/07/20/538171317/fact-check-trumps-confusing-remarks-to-senate-republicans-on-health-care
(C) Trump threatens electoral consequences for senators who oppose health bill, by Sean Sullivan, Kelsey Snell and David Nakamura, https://www.washingtonpost.com/powerpost/trump-challenges-senators-to-resurrect-obamcare-repeal-effort-were-close/2017/07/19/468c2dc0-6c8f-11e7-9c15-177740635e83_story.html?utm_term=.bd1cd4cb38f1
(D) McConnell prods senators on health care bill, amid dim odds, by Erica Werner and Alan Fram, http://abcnews.go.com/Health/wireStory/gop-senators-ditch-rescue-health-care-bill-48740322
(E) Senate Republicans Report New Life On Their Health Care Bill, by Matt Fuller, http://www.huffingtonpost.com/entry/senate-republicans-new-life-health-care_us_59702f8be4b0aa14ea7711b7
(F) The Paradox of Mitch McConnell’s Repeal-Only Vote, by David Frum, https://www.theatlantic.com/politics/archive/2017/07/the-paradox-of-mitch-mcconnells-repeal-only-vote/534129/
(G) The Trumpcare Bonfire, https://www.nytimes.com/2017/07/18/opinion/trumpcare-obamacare-let-it-fail.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

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“Houston Braces for Another Brush With the Peril of Zika” *. But they are doing passive not active surveillance. IS YOU AREA’S HEALTH CARE SYSTEM PREPARED FOR A SURGE OF AN EMERGING VIRUS LIKE ZIKA?

“With 4.5 million people in a hot, muggy metropolis built atop a bayou, America’s fourth-largest city, Houston, is a perfect target for the mosquito-borne Zika virus. But it may be better prepared than any other urban center to stop an outbreak.
The city last year increased its mosquito-control budget by 33 percent. Officials are testing new high-tech traps and have plans to release genetically modified mosquitoes that produce short-lived offspring, reducing the population.
Should the virus start spreading here, officials are prepared to follow Miami’s example, beginning aerial spraying and house-to-house inspections to clear standing water in which mosquitoes breed.”

“The biggest weakness in the county’s defenses is that officials still do “passive surveillance” for cases of Zika infection — meaning they must wait for doctors to report them.
Not every doctor who sees a rash and red eyes thinks of Zika. Test results can take weeks, and doctors often fail to alert the health department to new cases, even though they are legally required to do so.
Months could elapse before the city realizes the virus has appeared. A recent paper in Nature concluded that Zika actually arrived in Miami in March or April, but was not detected until July.”


* Houston Braces for Another Brush With the Peril of Zika by Donald G. McNeil Jr., https://www.nytimes.com/2017/07/17/health/zika-virus-houston-texas.html

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