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Senate Health Care Vote: Narrow Repeal Measure Takes Shape

Then there’s the question of what would come next. Republican leaders are assuring senators that the narrow repeal would be merely a vehicle to begin negotiations with House Republicans on a broader compromise to repeal and replace the Affordable Care Act. But some senators worry that they are being asked to vote for legislation they don’t like on a promise that it won’t become law — but they have no guarantee that the House won’t take it up and pass it.

Parliamentarian takes another scalp.

Senate Republicans also would have liked the “skinny repeal” to include a measure that would make it much easier for states to waive federal requirements that health insurance plans provide consumers with a minimum set of benefits like maternity care and prescription drugs.

Then the Senate parliamentarian stepped in. The parliamentarian, Elizabeth MacDonough, objected on Thursday to the waiver provision, saying it appeared to violate Senate rules being used to speed passage of the bill to repeal much of the Affordable Care Act.

Republicans want to make it easier for states to get waivers for two reasons: State officials can regulate insurance better than federal officials, they say, and the federal standards established by the Affordable Care Act have driven up insurance costs.

But Republicans are learning the limits of the fast-track rules they are using. The Senate is considering the repeal bill under special procedures that preclude a Democratic filibuster, but the procedures also limit what can be included in the bill.

“The function of reconciliation is to adjust federal spending and revenue, not to enact major changes in social policy,” said Senator Bernie Sanders, independent of Vermont. “The parliamentarian’s latest decision reveals once again that Republicans have abused the reconciliation process in an attempt to radically change one-sixth of the American economy by repealing the Affordable Care Act.”

The Senate bill would give states sweeping new authority to opt out of federal insurance standards established by the Affordable Care Act. It builds on a section of the law that allows states to obtain waivers for innovative health programs. But it would relax many of the requirements for such waivers that Democrats put into the law, signed by President Barack Obama in 2010.


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Insurers come off sidelines with warning.

The health insurance lobby, America’s Health Insurance Plans, came off the sidelines on Thursday to warn Senate leaders against repealing the Affordable Care Act’s mandate that most Americans have insurance without approving some mechanism to pressure people to maintain their coverage.

“We would oppose an approach that eliminates the individual coverage requirement, does not offer continuous coverage solutions, and does not include measures to immediately stabilize the individual market,” the group wrote.

AHIP played a major role in getting the Affordable Care Act passed in 2010 but has been reluctant to intervene in the fight over its repeal. On Wednesday, the Blue Cross Blue Shield Association, a narrower insurance lobby, weighed in with a similar warning.

Both groups were pulled into the fray by expectations that the Senate could end up voting in the early morning hours of Friday on a narrow bill that repeals a few important parts of the Affordable Care Act but leaves much of the law in place. Two of the pieces that would be repealed are the mandates that individuals have health insurance and that large employers cover their employees. The Senate had intended to repeal those mandates but create a new rule that anyone who allows coverage to lapse would have to wait six months before getting a new policy.

That lock out period was supposed to be enough to convince people not to simply wait until they were sick to buy insurance, a prospect that could send insurance markets into a tailspin, since only sick people would have insurance.

But it looks certain that any bill that can emerge from the Senate would not have the lock out provision, a deep concern to insurers who say that without it, insurance premiums would soar.

The American Medical Association piles on.

The American Medical Association, by far the largest physicians’ advocacy group, has stood firmly against each of the bills to repeal the Affordable Care Act. Now the A.M.A. has come out against the “skinny repeal.”

“There has been considerable speculation regarding a so-called ‘skinny package’ that would primarily eliminate penalties related to the individual and employer mandates and provide tax cuts to device manufactures and the health insurance industry. Eliminating the mandate to obtain coverage only exacerbates the affordability problem that critics say they want to address. Instead, it leads to adverse selection that would increase premiums and destabilize the individual market.

“We again urge the Senate to engage in a bipartisan process – through regular order – to address the shortcomings of the Affordable Care Act and achieve the goal of providing access to quality, affordable health care coverage to more Americans.”

Oh, and so does AARP.

Protesters make their voices known.

Across the Capitol on Thursday, supporters of the Affordable Care Act tried to reach out to senators, sometimes through mass protests, sometimes through their stories.


How Many People Across America Are at Risk of Losing Their Health Insurance?

A state-by-state look at who could lose insurance under the proposed Republican health care plans.

“I had epilepsy as a kid. I would not have been able to be covered under what you’re proposing,” one man told Senator Richard Shelby, Republican of Alabama.


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The senator replied: “I think we need to have — not just for you but for any group that is underserved medically — we ought to protect them.”

Vigils broke out throughout the Capitol and around lawmakers’ offices.

Protesters in the Senate gallery chanting “kill the bill” disrupted proceedings on Tuesday just before the Senate voted, 51-50, to begin the health care debate. Democrats, including Senator Cory Booker of New Jersey, spoke to crowds on the steps of the building. Hundreds of protesters flooded the lawns outside the Capitol.

“The message was: we are not backing down,” Nora Franco, campaign organizer at Planned Parenthood, said in the Capitol. She added, “Now is not the time to throw in the towel. Now is the time to literally be harassing your senators.”

Seven years ago, similar scenes unfolded before the votes on the Affordable Care Act, but then, the passion came from the opponents. Those voices now are little in evidence.

Has Alaska’s delegation crossed Trump?

President Trump went after Senator Lisa Murkowski of Alaska, who was one of only two Republicans to vote against starting debate on health care this week, with a Twitter post on Wednesday.

But that might not be the end of it.

Ryan Zinke, the Interior secretary, called both Ms. Murkowski and Alaska’s other senator, Dan Sullivan, “letting them know the vote had put Alaska’s future with the administration in jeopardy,” The Alaska Dispatch News reported. Mr. Sullivan, also a Republican, voted in favor of beginning debate.

“I’m not going to go into the details, but I fear that the strong economic growth, pro-energy, pro-mining, pro-jobs and personnel from Alaska who are part of those policies are going to stop,” Mr. Sullivan said, according to the newspaper.


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But the leverage goes both ways.

Ms. Murkowski is the chairwoman of the Senate Energy and Natural Resources Committee, which has oversight of the Interior Department. She is also the chairwoman of the Senate Appropriations subcommittee with jurisdiction over the department.

She likely can do more to Mr. Zinke than he can do to her.

Tracked down by reporters on Capitol Hill, Mr. Sullivan called for the administration and Alaska’s small but powerful congressional delegation to “get back to cooperation.”

No word yet from Ms. Murkowski.

Where did the Senate leave off on Wednesday?

Wednesday’s big vote was on a measure to repeal major parts of the existing health law — but without swapping in something new.

Republicans have struggled to agree on the contents of a replacement for the law, so a “clean repeal” bill seemed like a good alternative to some of them.

But the measure was soundly rejected. Seven Republicans — including Senator Lamar Alexander of Tennessee, the chairman of the Senate health committee — joined Democrats in voting against it.

The repeal-only measure was expected to fail. But the episode demonstrated the problem facing Republican leaders: They don’t have enough votes to pass a broad replacement of the health law. They also don’t have the votes to simply repeal major parts of it.


The Outcomes of the Many Republican Health Plans Are Not So Different

Comparing how the plans would affect key measures like the number of uninsured and the deficit.

What happens on Thursday?

Senate Republicans have been trying to push through a repeal by using special budget rules that limit debate to 20 hours. That time is expected to be exhausted on Thursday.

After it expires, the Senate will move into what is known as a “vote-a-rama” — a marathon series of votes on amendments.


Senator Chuck Schumer, the minority leader, leaving the Senate chamber after lawmakers on Wednesday rejected a proposal to repeal the health care law.

Stephen Crowley/The New York Times

Typically, Democrats would be expected to offer a barrage of amendments. But on Wednesday night, the minority leader, Chuck Schumer of New York, said Democrats would not offer any amendments until Mr. McConnell revealed the final bill he wants the Senate to consider.


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“We ought to see it soon, in broad daylight, not at the 11th hour,” Mr. Schumer said.

The vote-a-rama could begin late in the day on Thursday. If Democrats do offer a blizzard of amendments, it could stretch overnight. But it remains unclear when, exactly, Mr. McConnell plans to reveal his legislation.

Republicans seem increasingly likely to try to pass a slimmed-down bill that would repeal only a small number of the existing health law’s provisions. By passing a so-called “skinny” repeal bill, Senate Republicans would keep the repeal effort alive long enough to try to negotiate a broader compromise bill with the House of Representatives.

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AF extends Health Professions Loan Repayment Program

/ Published July 27, 2017

Application packages for the Air Force’s Health Professions Loan Repayment Program will now be accepted until Sept. 1, 2017. Active-duty Biomedical Sciences Corps and Nurse Corps officers are eligible to apply. 
HPLRP provides an incentive for current active-duty medical personnel to extend their active duty commitment through the repayment of professional educational loans, provided they are in the selected career fields and otherwise eligible.
“We want our people to be able to balance their commitment to serve their country and support their families,” said Maj. Connie Converse, a Biomedical Sciences Corps utilization officer at the Air Force Personnel Center. “This initiative helps alleviate some of the financial burden of student loans, instilling greater confidence about their futures and allowing greater flexibility for families.”
The maximum loan repayment is $40,000 per year for up to two years, minus about 28 percent in federal income taxes, which are taken out prior to lender repayment. 

“The loan repayment counts as income,” Converse said. “We encourage officers with questions about the tax effects to consult with their tax expert prior to applying for the program.” 

Repayment may consist of loan amounts for principal, interest and reasonable educational and living expenses, and are sent directly to the lending institution on behalf of the HPLRP participant. 

Officers may use HPLRP to repay any qualified loans obtained for their qualifying degree that allows them to hold their Air Force Specialty Code. 

“The Air Force Officer Classification Directory on myPers is the source document that provides the type of qualifying degree the member requires in order to obtain their commission,” Converse said. “The expense to obtain that degree is what the Air Force considers eligible debt for this program.” 

The service commitment for HPLRP is a minimum of two years, Converse said. 

Find additional information about the application requirements and process on myPers. Select “Active Duty Officer” from the dropdown menu and search “HPLRP.”
For more information about Air Force personnel programs, go to myPers. Individuals who do not have a myPers account can request one by following these instructions.



health professionals

JB San Antonio-Randolph

loan repayment




taking care of people

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The 5 Habits That Actually Contribute To Longterm Health, According To Science

To look around at all the health articles, tips, tricks, listicles and books, you’d think health was an extraordinarily complicated matter—and must arise from some elusive combination of interval training, crossword puzzles, and avocados. But it’s not actually that complicated. In fact, what science knows to contribute to health is just a simple handful of things: We should exercise, eat well, sleep enough, avoid toxins, and take care of our mental health. All the other bits of advice generally fall within these five categories. Of course, there are some things that are outside of our control, like genetic predisposition and autoimmune disease. But of the part that we do have control over, the behaviors that define health aren’t all that complex.


And it’s why public health experts are so frustrated with all the extraneous and needlessly complicated information floating around these days. “There are so many false narratives today (fake health news) that people genuinely are confused,” says David L. Katz, founding director of the Prevention Research Center at Yale University and the True Health Initiative. Some people may not know what to do, and others, even if they know what to do, may not have the means to do it. “There are people living with such constant daily challenges,” adds Katz, “that they never even think about health until it becomes the most urgent crisis du jour.”

Here’s a rundown of the five main habits that contribute to health, and why they actually do this. How to help people implement them is again the harder question.


Move your body

Most people are generally aware that exercise is good for them, but may not be clear on exactly why this is. It’s not just a method of staying thin or getting fitwhere exercise is really powerful is in its effects on the risk of chronic disease. Exercise has been shown to contribute to heart health in a number of ways, from helping reduce blood pressure to affecting the vasculature in our bodies to helping maintaining our cholesterol balance (the “good”-to-”bad” ratio), and increasing insulin sensitivity. Regular exercise also benefits the immune system, reducing inflammatory markers like CRP, IL-6 and TNF, which are known to be associated with chronic disease. Exercise is also well known to reduce cancer risk, for multiple types of cancer. And it’s excellent for the brain: It helps treat mental health disorders like depression, boosts the production new neurons in the hippocampus, and regulates the endocrine system, including stress response and the cascade of hormones that underlie it. Importantly, exercise is also linked to a reduced risk of brain diseases like Alzheimer’s disease and vascular dementia.

On the flip side, being sedentary is linked to a host of ill effects, from Alzheimer’s disease to heart disease to cancer to premature death. Both observational studies—in people who get regular exercise and in people who don’t—and lab studies that illuminate the cellular and molecular mechanisms show that exercise is one of the central things we can do for our health.

Eat a plant-based diet

This one has been illustrated again and again in various ways. Large-scale epidemiological studies have shown that people who eat a largely plant-based diet are less prone to disease and live longer than people who eat other types—you don’t have to be vegetarian or vegan, but a diet that’s based largely on plants does seem necessary. A study a couple of years ago even showed that switching diets (from a typical meaty American diet to a plant-based rural South African diet and vice-versa) altered the microbiome and the inflammatory markers involved in colon cancer risk in a relatively short amount of time. Other research has shown that a plant-based diet reduces the risk of heart disease, dementia, cancer, metabolic disease, overweight and obesity, and diabetes.

The star of diets in recent years has been the Mediterranean diet, or a version of it, like the MIND diet. These diets include copious amounts of vegetables and fresh fruits (although the MIND diet excludes fruits, because of their relatively high sugar content), whole grains, nuts, legumes, fish, and healthy fats like olive oil. It limits dairy, meat, processed foods, alcohol (though a little red wine is ok) and, importantly, sugar. The research in the last decade has highlighted the fact that sugar actually presents a much larger health risk than fats; in fact, there’s no formal upper limit on fats anymore, assuming that they’re healthy ones. Cutting out processed foods including sugar, and eating as many foods in their natural form, or close to it, as we can, is probably one of single best changes we can make for long-term health.



The purpose of this mysterious nightly behavior eluded researchers for many years, but it’s starting to become clearer. Sleep serves a number of purposes, particularly for the brain, which can’t survive without it. While we’re sleeping, the brain actively prunes connections that we don’t need anymore, and perhaps even more crucial than this, it clears out the “gunk” that contributes to Alzheimer’s disease—by the same token, sleep deprivation is linked to a heightened risk of Alzheimer’s. Sleep loss, and the stress and hormone dysregulation that comes of it, is linked to a host of other problems, including weight gain, metabolic syndrome, diabetes, inflammation, depression, stroke and heart disease.

Aiming for between seven and nine hours per night for adults is generally a good rule of thumb. (If you’re getting or need much less or much more than this, it might be a sign of a health problem, so this should be checked out.)


Make your mental health a real priority 

This is one of the most fascinating ones, as it underlines how big an influence our mental health has on our physical health. It actually contains a couple of points, which are separate but related. The first part is taking care of your own internal mental health, and treating mental health disorders when they arise. Depression, anxiety, addiction and chronic stress all raise the risk of other diseases and the risk of early mortality.

Also under the umbrella of mental health is staying socially connected. An almost 80-year long Harvard study has found that a key indicator of a person’s health and longevity was whether he or she had rich social connections. This may work for a couple of reasons: We’re social creatures by nature, and being around other people is a huge stress relief and mood booster. Additionally, having a social network, including a partner, may also make it more likely that you’ll take better care of yourself along the way, and seek medical care when problems arise. 

There are other, more specific elements that fall under this category—for instance, having a life purpose outside yourself is also linked to a significantly longer life and to improved inflammatory gene expression. And staying cognitively active by engaging in hobbies, crossword puzzles, and brain games may help, but the research is a little more mixed there.


Avoid taking in harmful chemicals, and critters, as much as possible

This one includes the big carcinogen, which still kills way too many people about the globe—tobacco. It also covers drinking, which, if you’re going to do it, should probably fall into the “light” category. The tobacco literature speaks for itself, but the research on alcohol is only just becoming clearer. Some researchers believe that moderate drinking is ok and even beneficial for reducing disease risk, but recent studies have suggested that even light drinking confers some level of cancer risk. Therefore, very light drinking is probably the best advice, and not to start drinking for the health benefits if you don’t currently.

This category also includes exposure to other toxins, carcinogens and endocrine disruptors, from smog to beauty products to plastics. There are lots of “bad chemicals” out there and it’s impossible to avoid everything; but cutting down where we can is probably smart. The use of OTC meds like acetaminophen and ibuprofen should probably be sparing, since they’ve also been shown to have some long term risks.

Finally, also in this category is trying to reduce our exposure to bacteria and viruses—within reason. This includes everything from practicing safe sex to washing your hands regularly to getting vaccinated. The antibacterial craze has largely backfired, so you don’t have to go crazy with antibacterial soap and wipes. Let your kids play in the dirt and with the pets. A little exposure to germs (again, within reason) can actually be a good thing.

* * *  

Again, a healthy lifestyle is not really all that complicated. It boils down to just a handful of behaviors. But this is also what makes it so difficult—that these things are, in the end, all behaviors, which means it’s up to us to be aware of them and to see them through.

And, of course, the relevant organizations need to agree on what the healthy behaviors actually are, and not get swayed by big food, lobbyists, and advertising. The trick then is how to make these basic habits common knowledge. Says Katz, “if we actually could rally our culture to clarity about where ‘there’ is, we might devote more resources to getting there from here. And we might be less complacent about such hypocrisies as lamenting the prevalence of type 2 diabetes in children, while introducing the attached new products as part of every kid’s ‘complete breakfast.’ There should be collective outrage—but there isn’t.”

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Senate Health Bill’s Only Win May Be Tax Relief To Device Makers

The “motion to proceed” in the U.S. Senate on debate over the future of the Affordable Care Act may mean only that a tax on medical devices disappears permanently, given early votes to gut the entire law have already been unsuccessful.

The tax on medical device sales is perhaps the least objectionable in all of the amendments the Republican-led U.S. Senate is considering this week and would seemingly have the least impact to patient care or health insurance coverage, supporters and one new analysis indicate.

Senator John McCain (R-Arizona) walks into the U.S. Senate chamber on July 25, 2017 in Washington, D.C. (Photo: Mark Wilson/Getty Images)

Key Republican senators remain opposed to Senator Mitch McConnell’s Better Care Reconciliation Act and House Speaker Paul Ryan’s American Health Care Act because they will cause more than 20 million Americans to lose coverage in less than a decade. Those coverage losses from either Trumpcare bill come largely from a rollback of the ACA’s Medicaid expansion in 31 states.

Meanwhile, a third option to health reform legislation began to emerge Tuesday that would also include repeal of the device tax. The so-called “skinny repeal” would eliminate the individual mandate, the employer mandate and the medical device tax.

The two mandates are unpopular among most Republicans but could cause millions to lose coverage. The individual mandate, which requires Americans to have coverage or face a penalty, would “increase the number of uninsured individuals by 15 million by 2026 and increase premiums in the individual insurance market by 20%” the Committee for a Responsible Federal Budget said Tuesday afternoon.

The mandates may not survive unless lawmakers come up with a way to prevent millions of Americans from losing coverage, which has been a sticking point for some GOP moderate senators.

But the 2.3% tax on medical device sales has already been on temporary hiatus since the beginning of last year and is scheduled to expire at the end of this year. It’s also perhaps one of few, if any, items in the bills to have bipartisan support with Democrats like Senator Amy Klobuchar of Minnesota supporting a permanent repeal of the device tax.

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Huge drop in sperm count could lead to human EXTINCTION: Study reveals 60% drop in fertility since 1970 – driven by …

  • Study found a nearly 60 percent decline in sperm count in Western men between 1973 and 2011, a 37-year period
  • Sperm count is the best measure of male fertility, so the trend is alarming
  • Causes of decline have been linked to environmental and lifestyle factors
  • Experts say the findings are ‘an urgent wake-up call’ to investigate the drop

Abigail Miller For



Humans could face extinction if sperm counts continue to drop as fast as they have done in the last four decades in Western countries, a study warns. 

Researchers claim the Western lifestyle has more than halved the sperm count of men in the US, Europe and Australia since the 1970s in a new study published by Human Reproduction Update.

Sperm count is the best measure of male fertility, and lead author Dr Hagai Levine said the findings are an ‘urgent wake-up call’ to investigate lifestyle factors, chemicals and environment that could cause the human species to go extinct.

‘If we do not make a drastic change to how we live and the chemicals we are exposed to I am worried about the future,’ he told Daily Mail Online.  

‘I think the data serves as a wake up call, because I am personally worried about that [human extinction] if we do not address current environmental issues.’

Men in Western countries are becoming less fertile every year according to a new study (stock image)

Men in Western countries are becoming less fertile every year according to a new study (stock image)

Researchers at Hebrew University-Hadassah Braun School of Public Health and Community Medicine and the Icahn School of Medicine at Mount Sinai looked at 185 studies collected between 1973 and 2011 regarding sperm count and concentration in men from North America, Europe, Australia and New Zealand.

They found 59.3 percent average decline in total sperm count and a 52.4 percent average decline in sperm concentration among these men.

The men researched in those studies were not chosen for the studies based on their fertility status.

In contrast, there was no significant decline in South America, Asia and Africa, though far fewer studies have been conducted in those areas. 

The research team then restricted the studies with a sample collection between 1996 and 2011, and found the slope to be equally steep and significant, indicating that the rate of decline is not decreasing.  

This study did not examine causes of the decline, but it has previously been linked to environmental and lifestyle factors, such as exposure to chemicals and increased rates of obesity in Western countries. 

‘Given the importance of sperm counts for male fertility and human health, this study is an urgent wake-up call for researchers and health authorities around the world to investigate the causes of the sharp ongoing drop in sperm count, with the goal of prevention,’ said Dr Levine. 

Dr Levine also said the findings have public health implications because it demonstrates the proportion of men who are infertile are increasing. 

Additionally, recent studies have found that reduced sperm count is related to increased morbidity and mortality, meaning the ongoing decline points to serious risks to male fertility and male health. 

Sperm concentration: Researchers looked at 7,500 studies collected over the 37-year span and found that there was a 52.4 percent decline in sperm concentration

Sperm count: They also found a 59.3 percent decline in total sperm count in the men who were studied. Those men were not chosen based on fertility status 

Decline in sperm rate has previously been linked to environmental and lifestyle influences such as prenatal chemical exposure, adult pesticide exposure, smoking, stress and obesity.

‘Decreasing sperm count has been of great concern since it was first reported twenty-five years ago. This definitive study shows, for the first time, that this decline is strong and continuing,’ explained Dr Shanna H Swan from Mount Sinai Hospital in New York. 

‘The fact that the decline is seen in Western countries strongly suggests that chemicals in commerce are playing a causal role in this trend.’

The decline in sperm counts among Western men has been reported since 1992, but previous studies have been considered controversial due to limitations. 

In order to avoid those criticisms, in this study, researchers used a broader scope and rigorous meta-regression methods to conservatively address the reliability of study estimates.


They also controlled for factors that might explain the decline, such as age, abstinence time and selection of study population. 

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Why the GOPs ‘skinny’ health bill won’t pass either

<!– –>

Senate Majority Leader Mitch McConnell, accompanied by Senator John Cornyn (R-TX) and Senator John Barrasso (R-WY), speaks with reporters following the successful vote to open debate on a health care bill on Capitol Hill in Washington, July 25, 2017.

Now that the Senate has fallen well short of being able to to pass its more comprehensive Obamacare repeal and replacement bill, the Republican leadership’s hopes are increasingly pinned to a plan B some are calling the “skinny bill.”

Those hopes are about to be dashed too.

The “skinny bill” is a measure that would keep Obamacare’s Medicaid expansion and insurance subsidies in place but would eliminate the mandate requiring everyone to get insurance coverage or face a penalty. It would also kill the Obamacare medical device tax. Some people are calling it a “half a loaf” bill that at least moves the ball in the right direction for those who want to see all of Obamacare eventually abolished.

In theory, they’re right. Politics is about compromise, and ending the onerous insurance requirement for individuals and businesses would be a big victory for the repeal forces and those who favor less government intrusion.

The problem is, it’s not going to happen.

The reason is simple. Even with the mandate currently in place, there haven’t been enough younger and healthier people signing up for coverage. The Congressional Budget Office and lots of other supposed experts were way off the mark when they estimated how many people would sign up for insurance to avoid the penalties for not doing so. Without a robust stream of premium revenues from younger people who are less likely to need expensive care, many insurers have exited the least profitable ACA exchanges. This is what some call the “Obamacare death spiral.”

The skinny bill would accelerate this scenario in a big way. If the penalties and requirements for health insurance coverage haven’t coerced the expected number of people to buy insurance, just imagine how quickly those coverage levels will drop without them. More and more insurers would bolt the exchanges in that scenario as they wouldn’t want to wait around to lose money when enrollment numbers fall. And those who think there are 50 or more GOP senators who will allow that to happen are kidding themselves.

Because a closer look at the map of states where the Obamacare exchanges are already without multiple insurer options is decidedly Republican-dominated. It’s filled with red states like Alaska, South Carolina, Wyoming, Arizona, Mississippi, Alabama, and Oklahoma. Not all the GOP senators in those states will resist ending the mandate, but Arizona’s Senator John McCain said Tuesday he wasn’t ready to vote for any replacement bill and his state’s dwindling insurance options could be why. Without McCain alone, the “skinny bill” is doomed, and don’t be surprised if a few other Republicans like Alaska Senator Lisa Murkowski vote against it too.

But this isn’t just about protecting constituents from losing all their insurance coverage choices. From the beginning, Senate Majority Leader Mitch McConnell has put insurance company priorities at the top of his list in this Obamacare replacement process. The one thing he’s fought to keep in every bill is some form of subsidies to help Americans buy insurance plans, which is an indirect taxpayer money hand off to the insurance industry.

Even the “skinny bill” keeps those subsidies in place. But that won’t be enough for the insurance companies if the mandate is killed and fewer people are buying insurance. The Obamacare insurance mandate is a clear example of a government-imposed rule meant to boost a private industry; its powerful lobbyists aren’t letting go of it easily.

Throw in the very powerful argument that private health insurance exchanges in several states across the country could disappear in a hurry if the “skinny bill” is passed, and you can see why this measure is already dead on arrival.

Commentary by Jake Novak, senior columnist. Follow him on Twitter @jakejakeny.

For more insight from CNBC contributors, follow @CNBCopinion on Twitter.

Jake Novak

Crazy Talk: Cable News Cleared To Talk Trump’s Mental Health

Credit: Dennis Van Tine/MediaPunch/IPX

This is going to get messy–very, very messy.

If there’s one topic American journalists have never demonstrated an ability to cover with sobriety and nuance, it’s mental illness. Smart reporters who would never resort to stereotypes, cliches and myths fall into all those traps when attempting to discuss a person’s mental health.

But now, Stat reports, a leading psychiatry group has advised its members that the longstanding practice of refraining from commenting publicly on the mental state of public figures, known as the “Goldwater Rule,” should be lifted.

Cable news bookers will surely be seeking the most telegenic and opinionated of psychiatrists to diagnose Donald Trump, now that the executive committee of the American Psychoanalytic Association has told its 3,500 members that they should not be prevented from “using their knowledge responsibly.”

Responsibly. That’s not really the first word that springs to mind when you think of political coverage on television, where cable networks’ political panels shout nightly about the deeper meanings of the president’s latest tweet or handshake with a world leader.

Now you’d better gear up for psychiatrists and former White House communications staffers loudly arguing over whether the President of the United States is delusional, paranoid, obsessive-compulsive or mentally fit for office.

Dr. Prudence Gourguechon, a psychiatrist in Chicago and past president of the American Psychoanalytic Association, told Stat “Trump’s behavior is so different from anything we’ve seen before.”

It’s reasonable to assume that many psychiatrists, having never consulted with or treated the president, will offer measured evaluations of Trump’s mental health. But don’t count on TV news doing the same.

In June, MSNBC’s Mika Brzezinski said of the president, “I think he’s such a narcissist, it’s possible that he is mentally ill in a way.” In a way? You see, here’s the problem with the news media and mental illness: they don’t approach it like a physical illness. No journalist would say someone was diabetic in a way. Mental illness–and especially the language associated with it–becomes shorthand for political commentary and, often, insults.

In May, in a segment on the Fox News Channel, a Yale professor said, “We know that if Donald Trump literally means the things he’s said, then he would be psychotic.” Dr. John Gartner said pointed to Trump’s tweets calling the crowd at his inauguration larger than that of President Obama as proof Trump was either delusional or a “psychopathic liar.”

What we will likely see are dozens of politically-driven debates in the guise of a mental health conversation, with the result being even less understanding among viewers of what real mental illness looks like. When Jimmy Kimmel aired a compilation video of the president’s habit of moving things like his soda glass or papers when he sits down at a desk, Kimmel joked “I hope his new health care plan covers OCD.”

CNN reported on the video, not with Dr. Sanjay Gupta, but Jeanne Moos, who played it strictly for laughs, producing a story that included brief comments from a psychology professor, but no explanation that sliding coasters is not proof of anything, especially a life-altering mental illness like obsessive-compulsive disorder (trust me, I’m not a little OCD, I’ve actually got the real thing).

In fairness, though, Trump is the Offender-in-Chief when it comes to throwing around the language of mental illness just to attack his enemies in politics and the “fake news media.” He recently shot back at MSNBC’s Brzezinski, calling and her co-host Joe Scarborough “low I.Q. Crazy Mika” and “Psycho Joe” because they spoke “badly” of him on a TV show.

The American Psychological Association, in a guide for journalists, urges reporters to avoid “words like ‘crazy,’ ‘insane,’ ‘lunatic’ and ‘psycho.’ Because they are often used to say something hurtful, they put down those who live with mental illness. Using ‘crazy’ to describe a mentally healthy person doing bad things makes it seem like mental health is a choice. Mental health is medical health, not a bad choice or bad behavior.”

A search of Trump’s Twitter feed shows the president has used each of these words—-repeatedly. Trump has called Bernie Sanders, Jeb Bush, Ted Cruz, Megyn Kelly and New York Times columnist Maureen Dowd “crazy” for various reasons, and he’s called Brzezinski crazy on several occasions, and once last year suggested that she “had a mental breakdown” while talking about Trump on air. To Trump, “crazy” is shorthand for weak or failing.

In 2015, Trump asked if President Obama was “insane.” The year before, Trump said on Twitter “I am starting to think that there is something seriously wrong with President Obama’s mental health. Why won’t he stop the flights. Psycho!”

Trump likes the insults. He thinks they hurt, which of course, they do. And if psychiatrists, liberated from the 1960s-era Goldwater Rule, feel empowered to accept invitations to talk about President Trump’s mental health by scrutinizing his tweets, speeches or watching video of him sliding his water glass on a table, well “responsible” isn’t the word that’s on the tip of my tongue.

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Psychiatry group tells members they can defy ‘Goldwater rule’ and comment on Trump’s mental health


leading psychiatry group has told its members they should not feel bound by a longstanding rule against commenting publicly on the mental state of public figures — even the president.

The statement, an email this month from the executive committee of the American Psychoanalytic Association to its 3,500 members, represents the first significant crack in the profession’s decades-old united front aimed at preventing experts from discussing the psychiatric aspects of politicians’ behavior. It will likely make many of its members feel more comfortable speaking openly about President Trump’s mental health.

The impetus for the email was “belief in the value of psychoanalytic knowledge in explaining human behavior,” said psychoanalytic association past president Dr. Prudence Gourguechon, a psychiatrist in Chicago. “We don’t want to prohibit our members from using their knowledge responsibly.”


That responsibility is especially great today, she told STAT, “since Trump’s behavior is so different from anything we’ve seen before” in a commander in chief.

An increasing number of psychologists and psychiatrists have denounced the restriction as a “gag rule” and flouted it, with some arguing they have a “duty to warn” the public about what they see as Trump’s narcissism, impulsivity, poor attention span, paranoia, and other traits that, they believe, impair his ability to lead.

Reporters, pundits, and government officials “have been stumbling around trying to explain Trump’s unusual behavior,” from his seemingly compulsive tweeting to his grandiosity, said Dr. Leonard Glass, a psychiatrist at Harvard Medical School. The rule against psychiatrists offering their analysis of the emotions, thought patterns, and beliefs underlying such behaviors, Glass said, robs the public “of our professional judgment and prevents us from communicating our understanding” of the president’s mental state.

Last week, in an essay in Psychiatric Times, Glass called the prohibition on such communication “an unacceptable infringement on my right and duty” to discuss issues “where the perspective of psychiatrists could be very relevant and enlightening.” He ended the essay by announcing his resignation from the American Psychiatric Association, which adopted the rule in 1973. He had been a member for 41 years.

Called the “Goldwater rule,” the prohibition on offering opinions about the mental state of public figures was adopted after some psychiatrists answered a 1964 survey on whether Sen. Barry Goldwater, the Republican presidential candidate that year, was mentally fit for the Oval Office. The rule states that it is unethical to offer a professional opinion about a public figure’s mental health, including the presence or absence of a disorder, without that person’s consent and without doing a standard examination. In March, the psychiatric association reaffirmed the rule.

The group acted despite growing criticism that the Goldwater rule is outdated and even unethical for preventing psychiatrists from pointing out behaviors that raise questions about a government official’s mental state. No other medical specialty has such a rule; cardiologists are not prohibited from offering their views of an official’s fainting spell, for instance, as long as they make clear that they have not examined the person.

Although opposition to the Goldwater rule has existed for years, it intensified with Trump’s candidacy and then election. In October, a book titled “The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President” will be published.

“When the book comes out, there will be renewed furor about the Goldwater rule, since it is precisely about what is wrong with him,” said psychiatrist Dr. Lance Dodes, a retired professor at Harvard Medical School who is now in private practice in Los Angeles.

A number of psychologists have spoken to reporters about what Trump’s statements and actions might reveal about his emotional and cognitive state. Although the American Psychological Association “prefers” that its members not offer opinions on the psychology of someone they have not examined, it does not have a Goldwater rule and is not considering implementing one, an official told STAT.

The psychoanalytic association went further. In its July 6 email, it explicitly stated for the first time that the organization does not subscribe to the rule. That position had been implicit for years, but the association’s “leadership has been extremely reluctant to make a statement and publicly challenge the American Psychiatric Association,” said one psychoanalytic association member who asked not to be publicly identified criticizing the other group.

One stated rationale for the Goldwater rule is that psychiatrists need to examine patients in order to properly evaluate them. In fact, for decades the State Department and other federal agencies have asked psychiatrists to offer their views on the psychological state of foreign leaders, Glass pointed out, evidence that government officials believe it is possible to make informed inferences about mental states based on public behavior and speech.

“In the case of Donald Trump, there is an extraordinary abundance of speech and behavior on which one could form a judgment,” Glass said. “It’s not definitive, it’s an informed hypothesis, and one we should be able to offer rather than the stunning silence demanded by the Goldwater rule.”

The Goldwater rule has long been odd in that violating it carries no penalties. In principle the psychiatric association could file a complaint with a member’s state medical board. That has apparently never happened. Nor has the association ejected a member for violating the Goldwater rule. That is something it, as a private association, would be legally permitted to do.

A state agency, however, is subject to the U.S. Constitution, civil liberties experts say, and penalizing psychiatrists for speaking out would likely be a violation of their First Amendment rights.

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Senate Health Care Decision: Pence Breaks Senate Tie

Mr. Portman informed his state’s governor, John Kasich, that he too would vote on a procedural motion to take up a repeal bill.

The votes — coupled with Senator John McCain’s arrival — put Republican leaders and President Trump close to the 50 they need to move the process forward.

But that doesn’t mean a bill will ultimately pass. Mr. Heller warned, “If the final product isn’t improved for the state of Nevada, then I will not vote for it.”

Senator McCain’s arrival is set, with a crucial vote afterward.

Senator McCain, Republican of Arizona, arrived at the Capitol, despite a diagnosis of brain cancer, to cast his vote on whether to begin debating legislation to repeal the Affordable Care Act.

After seven months of strategizing, debate and closed-door meetings, the Senate finally is voting. Senate Republican leaders can afford to lose only two Republicans. One is almost certainly gone, Senator Susan Collins of Maine. Senator Lisa Murkowski of Alaska is still on the fence, but leaders think they can win her over. Senator Rand Paul of Kentucky, one of the most vocal opponents of the Republican bill to replace the health care law, now appears ready to at least debate it.

If the motion to begin debate passes, the first vote will be on legislation to repeal the Affordable Care Act without a replacement. That is likely to fail, and would be followed by a vote on the Senate Republican bill to replace the health law.

If that also fails, Senate leaders may fall back on a narrow bill that repeals the Affordable Care Act’s mandate that nearly everyone have health insurance, a separate mandate that most employers offer their employees health insurance and a repeal of the medical device tax.


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The goal of that would be to simply get senators to negotiations with the House on a final repeal measure.


What to Watch for in G.O.P. Health Care Showdown

Republicans are making another attempt to repeal and possibly replace the Affordable Care Act. But will they have the votes this time?

By NATALIE RENEAU and JONATHAN WEISMAN on Publish Date July 24, 2017.

Photo by Gabriella Demczuk for The New York Times.

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As a vote looms, Trump turns up the heat.

The Senate moved toward a showdown Tuesday afternoon on whether to begin debate on legislation to repeal the Affordable Care Act — and President Trump kept up a drumbeat on Twitter to force a yes vote.

That missive came after a stream of other Twitter posts intended to cajole, pressure and badger Senate Republicans, 50 of whom he needs just to start the debate on his promise to repeal former President Barack Obama’s signature domestic policy achievement.

And a man who has never apologized for questioning Senator McCain’s heroism in Vietnam was suddenly very appreciative of his decision to fly in from Arizona after his brain cancer diagnosis to cast a vote.

Obamacare is dead? Not so fast.

Centene, one of the largest health insurers offering coverage under the Affordable Care Act, continues to defy the Republican talking point that the individual market is collapsing. One of the rare insurers that increased its bet on the marketplaces as many of its competitors exited, the company reported higher quarterly profits on Tuesday.

“The marketplace business continues to be particularly strong, confirming our business-as-usual approach,” said Centene’s chief executive, Michael F. Neidorff, in a statement. The company said it expected the business to remain strong for the rest of 2017.

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The company reported significantly higher net earnings of $254 million for the three months ended June 30, compared to $170 million for the same quarter of 2016. Revenue climbed to $12 billion for the quarter, an increase from $11 billion.

The insurer, which has traditionally served low-income individuals who are eligible for Medicaid, covers 1.1 million people in the marketplaces. Centene, based in St. Louis, has also benefited from the Medicaid expansion, adding an additional 1.1 million members.

In a call with investors, Mr. Neidorff acknowledged “the headline noise” surrounding the various Republican proposals to replace the Affordable Care Act. He said the company was working closely with state and federal officials to try to stabilize the individual market. “It is a moving target with a long way to play out,” he said.


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Mr. Neidorff also emphasized the importance of government funding for subsidies to low-income people, saying the failure to provide them will only hurt the people who need them. President Trump has repeatedly threatened to end those subsidies. “The leaders in Washington bear a responsibility to ensure that doesn’t happen,” he said.

What is being voted on?

For years, Republicans have promised to repeal and replace the Affordable Care Act, which was President Barack Obama’s signature domestic achievement. But they have struggled to find a consensus on how, exactly, to go about dismantling the law and installing a replacement.

The Senate majority leader, Mitch McConnell of Kentucky, says it is time for a vote.

On Tuesday, he will have the Senate vote on a motion to proceed — in this case, on whether to take up a health care repeal bill that narrowly passed the House in May.

Nobody expects that bill to become law. Instead, it would essentially serve as the vehicle for the Senate’s legislation. The House bill’s text would be swapped out for the Senate’s preferred language, whatever that ultimately is.

How does the voting math break down?

Republicans hold 52 seats in the Senate, and to be successful, they need a majority for the motion to proceed. In a deadlock, Vice President Mike Pence would break the tie in favor of proceeding.

Only days after announcing he has brain cancer, Senator John McCain, Republican of Arizona, plans to return to the Senate on Tuesday. His presence means Mr. McConnell can afford for two Republicans to vote against the motion. If Mr. McCain had been absent, Mr. McConnell would have been able to lose only a single Republican.

At least one defection is all but certain: Senator Susan Collins of Maine indicated on Monday that she would vote against proceeding in just about every imaginable circumstance.

Which senators are pivotal votes?


Senator Rand Paul, Republican of Kentucky, last week on Capitol Hill.

Doug Mills/The New York Times

One big factor is what Mr. McConnell plans to do after the procedural vote.

For example, Senator Rand Paul of Kentucky is an expected “no” vote if after clearing the procedural hurdle, the Senate turns to a bill by Mr. McConnell to repeal and replace the health law. Mr. Paul detests that bill.


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On the other hand, Senators Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska indicated last week that they would not vote to proceed if Mr. McConnell afterward scheduled a vote on a bill to repeal the health law without providing a replacement.

In addition, a number of other Republican senators have expressed varying qualms, with varying degrees of certitude. They include Mike Lee of Utah, Jerry Moran of Kansas, Rob Portman of Ohio and Dean Heller of Nevada.

What happens if the vote succeeds?

Such a vote would start the debate in the Senate on health care. At some point, Mr. McConnell is expected to offer an amendment that would substitute a new measure for the text of the bill that passed the House. But it remains to be seen what that new measure would be. Republicans are trying to pass the bill using special budget rules that limit debate to 20 hours and prevent a Democratic filibuster.

What happens if the vote fails?

Republicans are not expected to abandon their repeal effort, but its future would appear bleak, at least in the short term.

“We’ll go back to the drawing board,” Senator John Thune of South Dakota, a member of the Republican leadership, said on “Fox News Sunday.” Of voting to repeal and replace the health law, he said, “It’s not a question of if, it’s a question of when.”

Recent history provides some support for Mr. Thune’s optimism. The repeal bill in the House was declared dead before coming back to life — and Republicans there ultimately succeeded in passing a bill.

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Why The GOP Health Plan Had To Fail

Photo: Mandel Ngan (AFP/Getty Images)

Pain is a more powerful emotion than pleasure. Loss has a far greater impact on the human psyche than gain. For these reasons, the Republican plan to “repeal and replace” the Affordable Care Act (ACA) had to fail. And if our nation fails to reform the healthcare delivery system as well, the impact will be even more painful.

Seven years ago, not long after the ACA became law, the GOP reassured supporters that repeal would happen—that for the good of the nation it had to happen. In drafting their replacement plan, legislators embraced healthcare spending reductions as a path to lower taxes. As a result, each of the healthcare bills introduced this term would cause tens of millions of Americans to lose their health coverage.

Congressional Republicans underestimated the pain this would cause. Now, they’re the ones feeling it. With healthcare reform efforts in limbo, President Trump resolved last week to “let Obamacare fail,” later telling White House reporters, “I’m not going to own it. I can tell you, the Republicans are not going to own it.”

No one can say when or whether those on Capitol Hill will make another attempt at repealing or replacing the ACA. But one thing is for certain: Reform or no reform, pain is coming. And for politicians, pain always has an owner.

The Source Of Pain

Elected officials on both sides of the aisle recognize that American healthcare today fails to deliver the quality and convenience patients deserve, especially given its $3 trillion annual price tag.

Healthcare today is dangerously expensive and inefficient, and will continue to be without radical change to the current system’s structure, financing and technology. For decades, these changes in care delivery have constituted the “third rail” of the debate, and few politicians have dared touch it. That’s because insurers, drug makers, national physician groups, hospitals and other institutional powers have openly, and effectively, lobbied against any legislation that would cause them financial harm.

This leaves the legislative process at an impasse. Unless care delivery is made more efficient, efforts to expand coverage, as Democrats desire, will demand higher taxes. And without delivery system reform, Republicans hoping to lower healthcare spending face the brutal reality that millions of people will lose coverage.

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