Ruth Pfau

Now that I’m older, I look at the obituaries more often. Sometimes you run into ones like this:

Dr. Pfau, while not widely covered in the Western media, was renowned in Pakistan for her efforts to stop the spread of leprosy, a bacterial infection also called Hansen’s disease that when untreated can cause disfigurement and blindness. Around the world, its victims have often been relegated to “leper colonies” and regarded as outcasts.

The Express Tribune of Pakistan once credited Dr. Pfau with having “single-handedly . . . turned the tide of leprosy in Pakistan and won the gratitude and personal attentions of people ranging from military rulers to elected ministers to the general public.”

She has a couple great quotes:

But diverted to Pakistan while waiting for her visa in 1958, she was to stumble upon leprosy, a disease she had never heard of in a country she did not know existed.

“Well if it doesn’t hit you the first time, I don’t think it will ever hit you,” she recalled, after first seeing leprosy during a visit to a makeshift dispensary built on a disused graveyard in Karachi.

“Actually the first patient who really made me decide was a young Pathan.

“He must have been my age, I was at this time not yet 30, and he crawled on hands and feet into this dispensary, acting as if this was quite normal, as if someone has to crawl there through that slime and dirt on hands and feet, like a dog.”

and:

“Not all of us can prevent a war; but most of us can help ease sufferings — of the body and the soul.”

After helping Pakistan to become the first Asian country to have leprosy under control, she also:

She has also assisted the country’s many forgotten displaced people and rescued victims from the 2005 earthquake and floods of 2010.

Like Mother Teresa, she was a European nun working for decades among people with leprosy but she thought they weren’t all that similar:

She said her focus was on removing the root of the problem – not just dealing with its symptoms – the same ethos that has served her so well over the years in Pakistan when dealing with poor, displaced and marginalised people.

“The most important thing is that we give them their dignity back,” she insisted.

We need more people in the world like her.

More about Medicaid cuts

The CBO has extended their estimate of what the Republican tax cut … errr healthcare plan will do to Medicaid:

In the Congressional Budget Office’s assessment, Medicaid spending under the Better Care Reconciliation Act of 2017 would be 26 percent lower in 2026 than it would be under the agency’s extended baseline, and the gap would widen to about 35 percent in 2036 (see Figure 1). under CBO’s extended baseline, overall Medicaid spending would grow 5.1 percent per year during the next two decades, in part because prices for medical services would increase. under this legislation, such spending would increase at a rate of 1.9 percent per year through 2026 and about 3.5 percent per year in the decade after that.

In CBO’s extended baseline, Medicaid spending is projected to be 2.0 percent of GDP in 2017 and 2.4 percent by 2036. The 35 percent reduction in that spending that CBO estimates for 2036 under this legislation would result in Medicaid spending of 1.6 percent of GDP.

That sure seems like a big cut.

Via here, Avalere Health looks at the impact for each state, for example my state of Massachusetts will see a decrease of 17% in funding for Medicaid by 2026 for a total cut of $9.7 billion. Thanks Republicans.

Senate version of Tax Cut bill cuts insurance for 22 million

So the CBO score for the Senate Republican’s tax-cut err healthcare bill is out and it’s about as bad as the House version:

CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026. In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the nongroup market—would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

They also note that the ACA is not failing:

Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan (which is the second-lowest-cost plan in their area providing specified benefits). The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, a small number of people live in areas of the country that have limited participation by insurers in the nongroup market under current law.

The rest of that second paragraph explains why there is a problem in small areas:

Several factors may lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.’

Yup, they conclude it’s because of the actions of Donald Trump (who has told the IRS not to enforce the penalty for the individual mandate and has said he might cut the future payments for the cost-sharing subsidies) and Republicans in general.

So, the final analysis is we have to cut insurance for 22 million people so there can be large tax cuts for the rich, the ultra rich, and major corporations.

The GOP Tax Cut is here

The Senate GOP has finally released its plan for massive tax cuts for the rich, what they call their healthcare bill. Other places will look at all the details, so I’ll just look at the important bits:

The 400 highest-income taxpayers alone would receive tax cuts worth about $33 billion from 2019 through 2028, which is more than the federal spending cuts from ending the Medicaid expansion in any one of 20 expansion states and the District of Columbia.  In fact, the tax cuts for the top 400 roughly equal the federal cost of maintaining the expansion in Nevada, West Virginia, Arkansas, and Alaska combined.  (See Figure 1.)  Policymakers face a stark choice: maintain the Medicaid expansion coverage for 726,000 people in these four states, or advance the pending legislation and cut taxes by millions of dollars a year for 400 households whose annual incomes average more than $300 million apiece.

I left that last bit in just for laughs–the choice for Republicans is clear: tax cuts for the ultra rich.

Households with incomes above $1 million a year would get annual tax cuts averaging more than $50,000 apiece

Meanwhile, the House-passed bill would spend about $700 billion from 2019 through 2028 on tax cuts mainly for high-income people and wealthy corporations from repealing the ACA taxes that fall on them, we estimate based on Joint Committee on Taxation data.

Now if you cut taxes by $700 billion you’re going to have to cut benefits by about the same amount. Since Republicans are back in power they no longer care about the deficit but Reconciliation rules (this bill is going through the Senate using this) means it can’t increase the deficit by much.

So, remember that this is what Republicans are for: cutting benefits to millions of who are poor or middle-class to pay for massive tax cuts for the rich and especially the ultra-rich.

Trump administration out to cut contraception

It seems that Trump officials in Health and Human Services lie as much as he does (via here):

Secretary Tom Price, who has claimed that “there’s not one” woman who can’t afford birth control on her own (despite the high up-front cost of the most reliable contraceptives).

She (Teresa Manning) insists that contraception is ineffective, despite evidence that hormonal methods are 91% effective and long-acting reversible contraceptives such as intrauterine devices (IUDs) are 99% effective at preventing pregnancy.

She (Charmaine Yoest) asserts that condoms (whose use reduces the risk of HIV transmission by at least 70%) do not protect against HIV or other sexually transmitted infections. Yoest also claims contraception does not reduce the number of abortions and says that to accept this argument “would be, frankly, carrying water for the other side to allow them to redefine the issue in that way.”

Yoest and Manning are joined by Katy Talento, who has been named to the Domestic Policy Council, in claiming that the most effective types of contraceptives cause infertility and miscarriages. Talento has published some particularly outlandish articles on this topic, mis-citing a 2012 study whose author disavowed her description of his work in asserting that contraceptives are “breaking your uterus.”

Even worse, Yoest continues to cite long-discredited studies that used retrospective reporting to support her assertion that abortion causes breast cancer, despite the overwhelming evidence to the contrary from properly constructed prospective studies. … Nor, as she has claimed, does abortion cause mental illness; in fact, a long-term study that compared women who were denied abortions with those who were able to obtain them revealed that it is being forced to carry an unwanted pregnancy to term that is associated with near-term adverse psychological outcomes.

Perhaps the most insidious and politically potent assertion by these appointees is that common forms of contraception are actually abortifacients.

Hormonal contraceptives work primarily by preventing ovulation and thereby preventing fertilization. Even in cases in which they affect the endometrium, studies more recent than those used for the initial Food and Drug Administration–approved labeling have shown they do not interrupt an established pregnancy.

These people are against contraception but they know that a large majority of Americans support the use of contraception:

More than nine-in-ten adults think using birth control is either morally acceptable (36%) or not a moral issue at all (57%); just 4% say using contraception is morally wrong.

so they try to bend the definition of contraception to claim it’s abortion. It’s not and they’re lying to try to get rid of contraception.

Republican tax-cut bill has no transparency

It seems Republicans don’t want anyone to know about their healthcare proposal:

This has become more evident each day, as the Senate plots out a secretive path toward Obamacare repeal — and top White House officials (including the president) consistently lie about what the House bill actually does.

There was even a brief moment Tuesday where Senate Republicans flirted with the idea of banning on-camera interviews in congressional hallways, a plan quickly reversed after outcry from the press.

Republicans decried the secrecy of the ACA but:

“There were hundreds of hearings and markups that lasted days — or in the case of the Senate Health, Education, Labor and Pensions Committee, months,” Rovner recalls in her piece.

Senators wanted to talk about the Affordable Care Act and why they believed they needed to pass it. They gave floor speech and after floor speech defending its provisions. Patients had months to lobby their legislators on particular issues that they thought were important. A few months ago I interviewed one woman, for example, who successfully lobbied former Sen. Kent Conrad (D-ND) to add a ban on lifetime limits in health insurance.

I remember Christmas Eve 2009 in particular, when I lived in New York and my roommate’s family came to visit for the holiday. They opened presents in our living room. I was holed up in my bedroom watching the Senate vote on the ACA, the culmination of a 25-day floor debate.

They really don’t want any time for the public to complain:

There are some factors that could slow down the Senate. In comparison to the House, the Senate is barred from voting on a bill before a cost and impact estimate is released from the nonpartisan CBO.

But if the Senate is to really vote before they leave town for a week on June 30th, a goal that many Republicans hope is still achievable, that leaves little time for the public to see legislation. A CBO score takes 10 to 14 days to produce. There are only 17 days left before the end of the month.

The approach is broadly similar to the process that produced the American Health Care Act in the House last month. At the time, leaders released a finished bill and voted on it within 24 hours — so fast that the Congressional Budget Office couldn’t estimate its cost and effects for another three weeks. The move was a jarring shift after years of promises from House GOP leaders to slow down major legislation and post all bills online several days before a vote.

That last bit is obviously ironic as Republicans never seem to have a problem breaking promises or norms.

Some Republicans are complaining about the secrecy:

“I’ve said from Day 1, and I’ll say it again,” said Senator Bob Corker, Republican of Tennessee. “The process is better if you do it in public, and that people get buy-in along the way and understand what’s going on. Obviously, that’s not the route that is being taken.”

Senator Ron Johnson, Republican of Wisconsin, offered a hint of the same frustration felt by Democrats seeking more information about the bill.

“I come from a manufacturing background,” Mr. Johnson said. “I’ve solved a lot of problems. It starts with information. Seems like around here, the last step is getting information, which doesn’t seem to be necessarily the most effective process.”

Mr. Paul said he had no plans to bring out the copy machine again, but he suggested that the Senate’s current course left something to be desired. “My preference would be a more open process in committees,” he said, “with hearings and people on both sides.”

but they obviously don’t really mean it. After all there are at least three Senate Republicans saying they would like the bill to be more open and yet it’s not open. Since there are 52 Republicans in the Senate and all Democrats are opposed to the bill, three Republicans could kill the bill. This gives them a lot of power and yet, somehow, they’re not using it to make the process more open. That tells you they don’t really care. Just like Republicans don’t care if millions of Americans lose their health insurance.

Trump/Republican Tax Cut as bad as predicted

The CBO has released their analysis of the tax cut disguised as a healthcare bill that passed the House:

CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under H.R. 1628 than under current law. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 23 million in 2026. In 2026, an estimated 51 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law. Under the legislation, a few million of those people would use tax credits to purchase policies that would not cover major medical risks.

They also compare how non-group insurance would fare under current law (Obamacare) to the new law:

Under Current Law. Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan. The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, some areas of the country have limited participation by insurers in the nongroup market under current law. Several factors could lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.

Under the Legislation. CBO and JCT anticipate that, under H.R. 1628, nongroup insurance markets would continue to be stable in many parts of the country. Although substantial uncertainty about how the new law would be implemented could lead insurers to withdraw from or not enter the nongroup market, several factors would bring about market stability in most states before 2020. In the agencies’ view, those key factors include subsidies to purchase insurance, which would maintain sufficient demand for insurance by people with low health care expenditures, and grants to states from the Patient and State Stability Fund, which would lower premiums by reducing the costs to insurers of people with high health care expenditures.

The agencies expect that the nongroup market in many areas of the country would continue to be stable in 2020 and later years as well, including in some states that obtain waivers from market regulations. Even though the new tax credits, which would take effect in 2020, would be structured differently from the current subsidies and would generally be less generous for those receiving subsidies under current law, other changes (including the money available through the Patient and State Stability Fund) would, in the agencies’ view, lower average premiums enough to attract a sufficient number of relatively healthy people to stabilize the market.

However, the agencies estimate that about one-sixth of the population resides in areas in which the nongroup market would start to become unstable beginning in 2020. That instability would result from market responses to decisions by some states to waive two provisions of federal law, as would be permitted under H.R. 1628. One type of waiver would allow states to modify the requirements governing essential health benefits (EHBs), which set minimum standards for the benefits that insurance in the nongroup and small-group markets must cover. A second type of waiver would allow insurers to set premiums on the basis of an individual’s health status if the person had not demonstrated continuous coverage; that is, the waiver would eliminate the requirement for what is termed community rating for premiums charged to such people. CBO and JCT anticipate that most healthy people applying for insurance in the nongroup market in those states would be able to choose between premiums based on their own expected health care costs (medically underwritten premiums) and premiums based on the average health care costs for people who share the same age and smoking status and who reside in the same geographic area (community-rated premiums). By choosing the former, people who are healthier than average would be able to purchase nongroup insurance with relatively low premiums.

Why it almost sounds like things will be worse under this legislation. But let’s get to the important part:

• Repealing the surtax on certain high-income taxpayers’ net investment income;
• Repealing the annual fee on health insurance providers;
• Reducing the income threshold for determining the medical care deduction;
• Delaying when the excise tax imposed on some health insurance plans with high premiums would go into effect; and
• Repealing the increase in the Hospital Insurance payroll tax rate for certain high-income taxpayers.

And here’s what that gets:

The chart below shows the tax changes (the first two major components mentioned) go almost entirely to the highest earning households, while providing little or no benefit to the bottom 80 percent of the income distribution.  In fact, TPC estimates that a $37,000 average annual tax cut will go to the 1 percent of the population with the highest earnings (annual income of over $772,000).  The top 0.1 percent of the income distribution would receive an annual tax cut of over $200,000 (annual income over $3.9 million).

In short, the bill drops 23 million people off insurance to give very large tax cuts to the rich. Now that’s the type of bill a Republican loves.

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