“For most of my surgical career, I gave out opioids like candy….” “With approximately 142 Americans dying every day”….” We need to take away the matches, not put out the fires.”

“President Donald Trump on Tuesday vowed his administration would beat the opioid epidemic by beefing up law enforcement, strengthening security on the southern border to stop illegal drugs from entering the country.
Trump, joined in Bedminster, New Jersey, by Health and Human Services Secretary Tom Price and other administration officials, emphasized a tough law-and-order approach, rather than new treatment or social programs, as the White House’s primary strategy for halting an epidemic that kills 142 Americans every day, according to federal statistics. (A)

“President Trump declined yesterday to declare the opioid epidemic sweeping the United States a national emergency, despite a recommendation last week by his own commission. Trump’s top health administrator, Health and Human Services Secretary Tom Price, argued that extra step wouldn’t have helped much anyway — and experts tend to agree. (B)

“How did this happen?
In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive. Opioid overdose rates began to increase. In 2015, more than 33,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid. That same year, an estimated 2 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers, and 591,000 suffered from a heroin use disorder (not mutually exclusive). Here is what we know about the opioid crisis:
Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them; Between 8 and 12 percent develop an opioid use disorder; An estimated 4 to 6 percent who misuse prescription opioids transition to heroin; About 80 percent of people who use heroin first misused prescription opioids.
This issue has become a public health crisis with devastating consequences including increases in opioid misuse and related overdoses, as well as the rising incidence of neonatal abstinence syndrome due to opioid use and misuse during pregnancy. The increase in injection drug use has also contributed to the spread of infectious diseases including HIV and hepatitis C. As seen throughout the history of medicine, science can be an important part of the solution in resolving such a public health crisis.” (C)

President Trump’s commission on the opioid crisis asked him Monday to declare a national emergency to deal with the epidemic.
The members of the bipartisan panel called the request their “first and most urgent recommendation.”
Mr. Trump created the commission in March, appointing Gov. Chris Christie of New Jersey to lead it. The panel held its first public meeting last month and was supposed to issue an interim report shortly afterward but delayed doing so until now. A final report is due in October.
“With approximately 142 Americans dying every day, America is enduring a death toll equal to Sept. 11 every three weeks,” the commission members wrote, referring to the 9/11 terrorist attacks. “Your declaration would empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the executive branch even further to deal with this loss of life.”
In addition to seeking an emergency declaration, the commission proposed waiving a federal rule that sharply limits the number of Medicaid recipients who can receive residential addiction treatment.
It also called for expanding access to medications that help treat opioid addiction, requiring “prescriber education initiatives” and providing model legislation for states to allow a standing order for anyone to receive naloxone, a drug used to reverse opioid overdoses. (D)

“Drug wholesalers shipped 780 million hydrocodone and oxycodone pills to West Virginia in just six years, a period when 1,728 people fatally overdosed on these two painkillers, according to an investigation by the Charleston Gazette-Mail.
That amounts to 433 of the frequently abused opioid pills for every man, woman and child in the state of 1.84 million people….
The drug distributors say they’re just middlemen in a highly regulated industry and that pills would never get in the hands of addicts and dealers if not for unscrupulous doctors who write illegal prescriptions, and pharmacists who turn a blind eye. (E)

“My own “Aha!” moment came recently after my father had gallbladder surgery and recovered comfortably at home with a single ibuprofen tablet. Wow. It directly contradicted my residency training 15 years ago, when I was taught to give every surgical patient a prescription for 30 to 90 opioid tablets upon discharge. Some of my mentors told me that overprescribing prevents late night phone calls asking for more. The medical community at that time ingrained in all of us that opioids were not addictive and urged liberal prescribing. So that’s exactly what we did.
The hundreds of excessive opioid prescriptions I wrote in 2015 alone (the last year for which national data are available) were a tiny part of the country’s 249 million opioid prescriptions filled that year, almost one for every American adult. Last year, America produced 14 billion opioid pills (40 for every U.S. citizen), mostly paid for by the American public in the form of tax dollars or increasing health insurance premiums.
Take C-section for example, one of the most common operations paid for by Medicaid tax dollars. Some doctors appropriately prescribe five to 10 opioid tablets after the procedure (in combination with non-opioid meds as recommended by the American Pain Society), while other doctors are still doing what I did for years — give every patient a bottle of 30-60 highly addictive opioid tablets. (F)

(A) Trump says he’ll beat opioid epidemic with law-and-order approach, by BRIANNA EHLEY, http://www.politico.com/story/2017/08/08/trump-opioid-epidemic-heroin-241416
(B) The Health 202: Trump doesn’t need to declare the opioid crisis a national emergency, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/08/09/the-health-202-trump-doesn-t-need-to-declare-the-opioid-crisis-a-national-emergency/5989eb7530fb045fdaef11bf/?utm_term=.ed73a64ab6bb
(C) Opioid Crisis, https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis
(D) White House Panel Recommends Declaring National Emergency on Opioids, by ABBY GOODNOUGH, (A https://www.nytimes.com/2017/07/31/health/opioid-crisis-trump-commission.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
(E) Probe reveals flood of 780M painkillers in 6 deadly years in West Virginia, http://www.cbsnews.com/news/probe-780-million-painkillers-in-6-years-west-virginia/
(F) Doctors like me must stop overprescribing opioids, by Marty Makary, https://www.nytimes.com/2017/07/31/health/opioid-crisis-trump-commission.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0

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“.. here’s the first thing I thought about: feel better, Hillary Clinton could be president..” (Senator McConnell) (A) “McCain Voted Against Health Care Bill…Because it Would ‘Screw’ Arizona.” (B)

Despite President Trump’s call to let Obamacare implode its unlikely come September that the Republicans in Congress, many facing reelection, will let Obamacare fail.
Here’s a wrap up as Congress goes on vacation.

“After the failure early Friday of the latest Republican plan to repeal the Affordable Care Act, President Trump said that he wants to “let ObamaCare implode, then deal.” Mr. Trump has already been doing three things to undermine important provisions of the health law, and there is more he could do.
What Trump can do: Weaken enforcement of the individual mandate; Impose work requirements for Medicaid recipients; Fail to do advertising or outreach; Make tax credits for premiums less generous; Defund subsidies that help people pay out-of-pocket costs; Redefine essential health benefits.” (C)

The politics are exceedingly tricky in a divided and dysfunctional Washington, but economists, insurers, doctors and health policy experts across the political spectrum agree that immediately addressing three or four basic shortcomings in the existing system would go a long way toward making the law more effective and financially stable. Stabilize the Markets. Reduce Drug Prices. Expand Access for Poor. (D)

“In an attempt to hit Republicans where it counts, Trump on Monday morning tweeted, “If ObamaCare is hurting people, & it is, why shouldn’t it hurt the insurance companies & why should Congress not be paying what public pays?” It was at once an effort to threaten insurers about withholding Obamacare cost-sharing reduction payments and to threaten Congress about the special treatment it receives under Obamacare.”(E)

‘The first part of Trump’s tweet appeared to be referring to the approximately $8 billion in cost-sharing reduction subsidies the federal government pays to insurers to lower the price of health coverage for low-income Americans.
The second part appeared to be a threat to end the employer contribution for Congress members and their staffs, who were moved from the normal federal employee health-care benefits program onto the Obamacare insurance exchanges as part of the 2010 health-care law.’ (F)

“Finance Committee Chairman Orrin Hatch of Utah, whose panel oversees both health care and tax policy, said he was ready to tackle taxes. “I think we are moving on to tax reform but that doesn’t mean we can’t do more than one thing at a time,” he said, adding that Senate Republicans should not vote on health care again unless there is “a reasonable chance of success.”” (G)

“A group of around 40 House Republicans and Democrats known as the Problem Solvers Caucus has endorsed an outline of ideas aimed at making urgent fixes to Obamacare. While there is no legislative text yet, members in the caucus are moving quickly to seize the defeat of a Senate bill last Friday to garner broader support for their proposals — and force the GOP to ditch its quest to gut the current health care law once and for all.
The group’s proposal includes mandatory funding for cost-sharing reduction payments; the creation of a stability fund; a repeal of the medical device tax; and increasing the employer mandate’s threshold so that companies with 500 employees or more, rather than 50, are required to provide workers with health insurance.” (H)

“The apparent demise of the Republican drive to scrap the Affordable Care Act may open the door to bipartisan fixes to the law. If it does, some of the proposals being touted by a bipartisan group of governors may get a hearing on Capitol Hill….
For example, the governors want the federal government to continue to provide subsidies to low-income Americans so they can afford to purchase insurance on the marketplaces. In 2017, the federal government is expected to give tax credits totaling $38 billion to about 9 million people.
The governors also insist that at least through 2018, the federal government should continue to make it easier for lower-income Americans who purchase coverage on the marketplaces to afford out-of-pocket expenses.” (I)

“Sen. Lamar Alexander, R-Tenn., the influential chairman of the Senate Health, Education, Labor and Pensions Committee, announced Tuesday that his panel would begin work in early September on legislation to “stabilize and strengthen the individual health insurance market” for 2018. He publicly urged Trump to continue making payments to health insurance companies to reimburse them for reducing the out-of-pocket medical expenses of low-income people.
In the House, two Republicans, Reps. Tom Reed of New York and Charlie Dent of Pennsylvania, teamed up with Democrats to promote incremental health legislation that also would fund the cost-sharing subsidies.
The two moves were a remarkable response to the president’s repeated threats to send health insurance markets into a tailspin. They offered tangible indications of cooperation between the parties after Republican efforts to scrap the Affordable Care Act collapsed in the Senate last week, all but ending the seven-year Republican quest to overturn President Obama’s signature domestic achievement. Lawmakers from both parties concede that the health law needs improvement, as consumers face sharp premium increases and a shrinking number of insurance options in many states.” (J)

“Independent health-care experts agree that the Affordable Care Act has resulted in the lowest percentage of uninsured Americans ever and the slowest rate of inflation in health-care spending in 50 years. Incentives in the law are improving the quality of care, Medicare beneficiaries have saved nearly $27 billion on prescription drugs, nearly 600,000 unnecessary hospital readmissions have been prevented and the cost of premiums in the individual market today is almost exactly where the Congressional Budget Office predicted it would be eight years ago. The law is also projected to reduce federal deficits by more than a trillion dollars in coming years.
That’s an impressive record, but serious repairs are needed. While most marketplaces are stable, some are in danger of collapse. Costs are still too high for many families, and uncertainty over federal policy is making it treacherous for plans to price premiums accurately.
Both Republicans and Democrats have already proposed remarkably similar solutions targeted to solve these problems. They are affordable, not technically difficult to implement and would help families in all parts of our country. And they demonstrate that the law — and all the good it has done — doesn’t need to be destroyed to make needed improvements.” (K)

(A) McConnell on healthcare failure: ‘Feel better, Hillary Clinton could be president’, by JULIA MANCHESTER, http://thehill.com/homenews/senate/345464-mcconnell-after-healthcare-failure-feel-better-hillary-clinton-could-be
(B) McCain Voted Against Health Care Bill…Because it Would ‘Screw’ Arizona, by Cortney O’Brien Cortney O’Brien, https://townhall.com/tipsheet/cortneyobrien/2017/08/02/why-mccain-voted-against-health-care-bill-n2363645
(C) 3 Things Trump Is Already Doing to ‘Let Obamacare Implode’, by By HAEYOUN PARK and MARGOT SANGER-KATZ, https://nyti.ms/2vDytIK
(D) How to Repair the Health Law (It’s Tricky but Not Impossible), By REED ABELSON, ABBY GOODNOUGH and KATIE THOMAS, https://www.nytimes.com/2017/07/29/health/aca-obamacare-repeal-how-to-fix-health-care.html
(E) Daily on Healthcare: Angry Trump demands GOP Senate pass healthcare bill … but McConnell’s fundamental problem remains, by Philip Klein and Robert King and Kimberly Leonard, http://www.washingtonexaminer.com/daily-on-healthcare-angry-trump-demands-gop-senate-pass-healthcare-bill-but-mcconnells-fundamental-problem-remains/article/2176736
(F) Trump threatens to end insurance payments if no health-care bill, https://www.cnbc.com/2017/07/30/trump-threatens-to-end-insurance-payments-if-no-health-care-bill.html
(G) Dejected Republicans on Obamacare repeal: Barring a miracle, ‘it’s over’, By Lauren Fox, MJ Lee and Ted Barrett, http://www.cnn.com/2017/07/31/politics/future-of-health-care/index.html
(H) After collapse of Obamacare repeal in the Senate, growing calls for bipartisanship, MJ LeeDeirdre Walsh Profile, by MJ Lee and Deirdre Walsh, http://edition.cnn.com/2017/07/31/politics/senate-health-care-bipartisanship/index.html
(I) A Bipartisan Health Care Fix? Governors Have Some Ideas, http://www.huffingtonpost.com/entry/a-bipartisan-health-care-fix-governors-have-some-ideas_us_59808b02e4b07c5ef3dc1827
(J) Congress bypasses Trump on health care, by Robert Pear and Thomas Kaplan, http://projects.registerguard.com/rg/news/local/35822579-75/congress-bypasses-trump-on-health-care.html.csp
(K) How Congress can get a second chance on health care, by Nancy-Ann DeParle and Phil Schiliro, http://projects.registerguard.com/rg/news/local/35822579-75/congress-bypasses-trump-on-health-care.html.csp


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What Congress, President Trump and Former President Obama are saying about healthcare

“Politically, the collapse of the repeal effort is potentially devastating for Republicans. It leaves Trump without a significant policy achievement in the critical first six months of his presidency; it casts a pall over the party’s coming drives to pass a budget and overhaul the tax code; and it exposes GOP lawmakers to rising anger from their conservative base.
Substantively, it leaves much work undone. While the ACA has made health insurance accessible to millions of Americans, it has failed to contain rising costs, especially in the individual insurance market, where people without access to employer-provided coverage buy policies. Without federal action — and additional cash — those marketplaces could become unstable.”
“ “The vote last night presents the Senate with an opportunity to start fresh,” McCain said in a statement. Democrats, too, expressed interest in working across the aisle, especially on a plan to make federal cost-sharing subsidies permanent. The subsidies — which will total about $7 billion this year and $10 billion in 2018 — reimburse insurers for reducing co-payments and deductibles for certain low-income customers, reducing their out-of-pocket costs….” (A)

“House Republicans are fed up and openly blaming their Senate colleagues across the Capitol for torpedoing their party’s pledge to repeal and replace Obamacare.
They headed home for a five-week summer recess having failed on a key policy goal they vowed to get done once they controlled Congress and the White House. And things aren’t getting any easier as major fiscal fights are hanging over them this fall.
House Speaker Paul Ryan, who spent weeks urging his members to hold their fire and give Senate Republicans some space to get a health care deal, didn’t hide his frustration at a closed-door meeting in the Capitol basement on Friday. He effectively threw the Senate under the bus, telling his colleagues that the House of Representatives was the only arm of the government that was working.” Their overall message to voters: don’t blame us, it’s all the Senate’s fault.”(B)

““Trump, meanwhile, continued to express mainly hostility toward the ACA. On Friday, he unleashed a series of tweets blaming “3 Republicans and 48 Democrats” in the Senate who “let the American people down” by rejecting the latest overhaul proposal.
“As I said from the beginning, let ObamaCare implode, then deal. Watch!” Trump wrote. He also called for Senate Republicans to abolish the filibuster — a venerable Senate procedure designed to protect the minority party that requires contentious matters to receive the votes of at least 60 senators.”” (C)

“President Obama has always said we should build on this law, just as members of both parties worked together to improve Social Security, Medicare, and Medicaid over the years,” the statement continues. President Obama still believes that it is possible for Congress to demonstrate the necessary bipartisanship and political courage to keep delivering on the promise of quality, affordable health insurance for every American.” (D)


(A) Republican divided on whom to blame for health-care defeat, and what to do next, by Juliet Eilperin, Paul Kane and David Weigel, https://www.washingtonpost.com/powerpost/senate-rejects-measure-to-partly-repeal-affordable-care-act-dealing-trump-and-gop-leaders-a-major-setback/2017/07/28/f2865b10-7364-11e7-8f39-eeb7d3a2d304_story.html?utm_term=.b7a201c0398
(B) House Republicans rail on Senate GOP for torpedoing health care, by Deirdre Walsh, Phil Mattingly, MJ Lee, Kristin Wilson and Lauren Fox, http://www.cnn.com/2017/07/28/politics/house-republicans-blame-senate-health-care/index.html
(C) Trump lashes out over healthcare reform failure, by: Barney Jopson and Sam Fleming, https://www.ft.com/content/60659e20-73b0-11e7-aca6-c6bd07df1a3c(
(D) Obama speaks out after GOP health care bill failure, https://www.aol.com/article/news/2017/07/28/obama-speaks-out-after-gop-health-care-bill-failure/23054794/


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The House and Senate played “dodgeball” not wanting to be held accountable when twenty million people, their constituents, would lose access to affordable care.

“The Senate in the early hours of Friday morning rejected a new, scaled-down Republican plan to repeal parts of the Affordable Care Act, derailing the Republicans’ seven-year campaign to dismantle President Barack Obama’s signature health care law and dealing a huge political setback to President Trump.
Senator John McCain of Arizona, who just this week returned to the Senate after receiving a diagnosis of brain cancer, cast the decisive vote to defeat the proposal, joining two other Republicans, Susan Collins of Maine and Lisa Murkowski of Alaska, in opposing it.
The 49-to-51 vote was also a humiliating setback for the Senate majority leader, Mitch McConnell of Kentucky, who has nurtured his reputation as a master tactician and spent the last three months trying to devise a repeal bill that could win support from members of his caucus. (A)

Several Republicans, in fact, said they would vote for this bill only if guaranteed that it would never, ever, ever become law. And then they voted on the legislation that many considered terrible and were devastated by its defeat. Senate Majority Leader Mitch McConnell was visibly upset.” (B)

“Senate Republicans unveiled a “skinny repeal,” a narrow measure to roll back parts of the Affordable Care Act. It would leave 15 million more Americans without insurance next year, the Congressional Budget Office said.
Speaker Ryan tried to reassure senators balking at the narrow bill, but he left the door open for “skinny” passage.” (C)

““Speaker Paul Ryan’s statement saying he would conference with the Senate on a healthcare bill is not sufficient enough for Sen. John McCain (R-Ariz.)
“I would like to have the kind of assurances he did not provide,” McCain told reporters.” (D)

“As the highly unusual process of passing a bill to repeal the Affordable Care Act drew to a close Thursday, a number of Republican senators said they would like to see the upper chamber return to normal.
After a process that included skipping the usual public hearings, beginning debate without a final bill and sending a bill to the House hoping it won’t pass, senators said they want to return to the usual process of passing legislation….
(Senators) Shelby and Crapo were echoing Sen. John McCain of Arizona, who, earlier this week decried the process that Senate Majority Leader Mitch McConnell used on the health care bill. McCain had just returned to the Senate after being diagnosed with brain cancer and undergoing surgery to remove a tumor.” (E)

6. You read that right: 1, 2, 3, 4, 5, 6 percent. Six. As the Senate prepares to vote on a “skinny repeal” version that its members haven’t seen – and don’t actually want to see enacted – a new statewide poll shows that half of Arizona voters would prefer to keep Obamacare but make revisions to the law. (F)

(A) Senate Rejects Slimmed-Down Obamacare Repeal as McCain Votes No, by Robe Pear and Thomas Kaplan, https://www.nytimes.com/2017/07/27/us/politics/obamacare-partial-repeal-senate-republicans-revolt.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(B) Senate Fails To Pass Latest GOP Health Care Bill by Tamara Keith, http://www.npr.org/2017/07/28/539945644/senate-fails-to-pass-latest-gop-health-care-bill
(C) Health Care Debate: Obamacare Repeal Fails as McCain Casts Decisive No Vote,By ROBERT PEAR, THOMAS KAPLAN and EMILY COCHRANE, https://www.nytimes.com/2017/07/27/us/politics/senate-health-care-vote.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(D) McCain says Ryan’s assurance on a healthcare bill is insufficient, by JESSIE HELLMANN, http://thehill.com/policy/healthcare/344254-two-gop-senators-say-ryans-assurance-on-a-healthcare-bill-is-insufficient
(E) Republicans Want the Senate to Return to Normal After Health Care by Jack Brewster, http://time.com/4877348/health-care-senate-norms-republicans/
(F) Only 6 percent of Arizona voters like Senate health care bill, by Laurie Roberts, http://www.azcentral.com/story/opinion/op-ed/laurieroberts/2017/07/27/only-6-percent-arizona-voters-support-senate-healthcare-bill-poll-says/518427001/


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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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