Locally transmitted ZIKA case in Texas! Are we ready?

“Officials in Texas reported what they believe is a case of mosquito transmission of the virus within the state’s border, the first within the continental United States this year.
If correct, it would be the first known instance of local mosquito transmission within the continental United States this year.” (A)

This past April –
“The state now recommends that all pregnant women in six South Texas counties — currently in their first and second trimester — should be tested for the Zika virus.
The Texas Department of State Health Services is expanding their guidance for Zika prevention for the 2017 mosquito season, as they prepare for additional local transmission of the virus, meaning people who have not recently traveled getting bitten by a mosquito and then infected. Most Texas cases, however, are travel-related.
Cameron, Hidalgo, Starr, Webb, Willacy and Zapata counties are included in the new guidance. In addition to women in their first or second trimester, any pregnant woman who has a rash and at least one other Zika symptom — fever, joint pain, or eye redness — should be tested as well.
For pregnant women in Texas not in the six listed counties, they should be tested if they have traveled to areas with ongoing Zika transmission, including any part of Mexico.” (B)

….. organizing principles are urgently need to be established for tiered Zika hospital preparedness. Here are some thoughts. (C)
1. There should not be an automatic default to just designating Ebola Centers as ZRRCs, although there is likely to be significant overlap. There should not be an automatic default to just designating Ebola Centers as ZRRCs, although there is likely to be significant overlap.
2. Zika Centers should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and Zika-related “reading” expertise).
3. National leadership in clinical trials.
4. A track record of successful, large scale clinical Rapid Response.
5. Organizational wherewithal to address intensive resource absorption.
6. Start preliminary planning for Zika care out of the initial designated ZRRCs.
Zika protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

(A) Case of Zika Virus, Likely Spread by Mosquito, Is Reported in Texas, by Donald McNeil Jr, https://www.nytimes.com/2017/07/26/health/zika-virus-mosquito-texas.html
(B) Texas prepares for more local transmission of the Zika virus, by Andy Jechow,http://kxan.com/2017/04/07/texas-prepares-for-more-local-transmission-of-the-zika-virus/
(C) Former hospital prez says: Designate local Zika centers now, http://doctordidyouwashyourhands.com/wp-admin/post.php?post=6528&action=edit


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Senator Graham said he could not support a “half-assed” plan that he called “politically” the “dumbest thing in history.”

“Senate leaders now hope they can convince a majority of senators to vote for a scaled-back bill that is being called a “skinny” repeal bill. This measure would reportedly rescind the ACA’s requirement that individuals have health insurance and that employers with 50 or more workers provide coverage for their employees. The bill also would eliminate a tax on medical devices that manufacturers have fought against since before the ACA was passed in 2010.
The Congressional Budget Office (CBO) has not published a score for this specific measure. But actuaries and the CBO in the past have said that if the individual mandate were eliminated, 15 million fewer people would have insurance, and premiums for older adults would escalate because many healthy people would drop their coverage and insurers would be left covering older and sicker Americans.” (A)

“With the economy stagnating and Congress bridling at President Richard Nixon’s heavy-handed spending controls, lawmakers in 1974 created a fast-track procedure to help make the tough decisions on rising budget deficits and swelling entitlement spending.
Since then, that process — called reconciliation — has been warped for many purposes, including large tax cuts, but never has it been used for the kind of complex policy making that Republicans are trying to do now with health care. And it is showing.”
One by one, key provisions and large blocks of text may be stripped from the Senate bill to repeal and replace the Affordable Care Act because the budget rules being used to pass the legislation are for budget matters — spending and taxation — not policy. (B)

“The Senate has entered the home stretch of the dramatic debate to overhaul Obamacare, with lawmakers bracing for what could be a long and grueling marathon series of votes that extends well into the night and morning. The Republican health care strategy: Pass bill first, fix it later
And the text of the GOP plan — a so-called “skinny bill” that rolls back Obamacare’s individual and employer mandates — remains unseen by senators or the public, although it was discussed during a closed-door lunch…
The outline, according to two sources who have viewed it, proposes: Repealing the individual mandate, repealing the employer mandate for a minimum of six years, providing greater flexibility to the states through the 1332 waiver, and defunding Planned Parenthood, directing those funds to Community Health Centers.
The Republican Party’s ongoing efforts to pass legislation to weaken the Affordable Care Act is expected to culminate in the famous Senate process known as vote-a-rama, in which senators can introduce an unlimited number of amendments — often for the purpose of driving home a political point and forcing colleagues in the other party to cast uncomfortable votes.(C)

“Four Republican senators — enough to sink a majority vote — said that they will only support the GOP’s “skinny” Obamacare repeal bill if they get assurances that a better plan will get hashed out in a conference committee with the House…
Graham said he could not support a “half-assed” plan that he called “politically” the “dumbest thing in history.” But he added that he could back the bill if he is promised that lawmakers could strike a better Obamacare replacement deal in conference…
Essentially, the senators said they would back the plan only with the assurance that the House will not pass the same bill.”(D)


(A) Senate Leaders Still Intent on Slashing Your Health Care, by Dena Bunis, http://www.aarp.org/politics-society/advocacy/info-2017/senate-rejects-health-care-repeal-no-replace-fd.html
(B) Republican Gamble on Fast-Track Rules for Health Care Hits Wall, by Robert Pear, https://www.nytimes.com/2017/07/26/us/politics/republican-fast-track-rules-obamacare-hits-wall.html
(C) Senate nearing end of health care debate period, preparing for a long night of votes, http://cw39.com/2017/07/27/senate-nearing-end-of-health-care-debate-period-preparing-for-a-long-night-of-votes/
(D) Four GOP senators shred ‘skinny’ Obamacare repeal — but leave the door open to voting for it, by Jacob Pramuk, http://www.cnbc.com/2017/07/27/mccain-graham-johnson-lay-out-terms-for-supporting-obamacare-repeal.html


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“It is clear that Mr. McConnell does not much care which of these proposals the Senate passes…. — he just wants to get a bill out of the Senate.” (A)

Maybe you’ve noticed that DOCTOR’S recent posts on TrumpCare are curatorial, not editorial. Only when congressional consideration is finished, and a bill is passed or not passed, will there be time to assess the impact.

“The Senate voted Wednesday to defeat a bill that would have repealed Obamacare within two years without any immediate plan to replace the sweeping health care law.
Senators voted 45-55 in favor of the bill, falling six votes short of the 51 needed to pass it. Seven Republicans voted against it: John McCain of Arizona, Dean Heller of Nevada, Susan Collins of Maine, Rob Portman of Ohio, Lamar Alexander of Tennessee, Lisa Murkowski of Alaska and Shelley Moore Capito of West Virginia.
The vote comes on the second day of a 20-hour Senate debate on health care as Republican leaders scramble to win enough votes from their own members to pass something to replace the Affordable Care Act. The Senate began its session Wednesday morning with about 17 hours left in the debate.”
“With the defeat of the comprehensive replacement bill and the “clean” repeal bill, GOP leaders are now looking to pass a “skinny repeal” bill that would make limited changes to Obamacare. It would likely strip out the law’s tax on medical devices and its requirements for individuals to buy health insurance and large employers to provide coverage for their workers.” (B)

“The Congressional Budget Office estimated the proposal would have resulted in 32 million more uninsured over the next decade. Three-quarters of the nation would live in areas with no insurers participating in the individual market by 2026, CBO said, leaving many without an option if they do not have employer-provided or government health insurance, such as Medicare or Medicaid.”
Back in 2015, the passage of that bill was largely viewed as a political messaging exercise: GOP lawmakers were keenly aware that Obama would not sign it into law.
But now, with Republican President Donald Trump in the White House and ready to sign a bill, the stakes are real — as are the realities of voting to repeal the current health care law without a replacement in place.” (C)

“Ignoring overwhelming public opposition to legislation that would destroy the Affordable Care Act, Senate Republicans voted on Tuesday to begin repealing that law without having any workable plan to replace it.
The majority leader, Mitch McConnell, browbeat and cajoled 50 members of his caucus to vote to begin a debate on health care without even telling the country which of several competing bills he wanted to pass. Vice President Mike Pence provided the tiebreaking vote. The proposals vary in severity, but all of them would leave millions more people without health insurance and make medical care unaffordable for many low-income and middle-class families. It is clear that Mr. McConnell does not much care which of these proposals the Senate passes; for whatever reason — pride, White House pressure, sheer cussedness — he just wants to get a bill out of the Senate. It could then go into conference with the House, which passed its own terrible bill in May. (A)

(A) The Senate’s Health Care Travesty, By THE EDITORIAL BOARD, https://www.nytimes.com/2017/07/25/opinion/senate-health-care-vote.html
(B) Where we are now on the Senate health care bill: Clean repeal dead as GOP plods through debate, by Erin Kelly and Eliza Collins, https://www.usatoday.com/story/news/politics/2017/07/26/senate-health-care-bill-whats-happening-now/511889001/
(C) Health care debate: Senate rejects full Obamacare repeal without replacement, by MJ Lee and Phil Mattingly, http://www.cnn.com/2017/07/26/politics/health-care-bill-wednesday/index.html

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“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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