In an unexpected turn of events, cows are helping scientists better understand how to prevent HIV infections.
One of the biggest questions facing researchers developing a vaccine against HIV is why people who are infected do not efficiently make antibodies against the virus. Scientists estimate that only about 20% of people who are infected with HIV produce what are called broadly neutralizing antibodies (bNAbs): naturally occurring antibodies that can defend a cell against the virus. Even among people who do produce them, that production typically starts around two years after infection.
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“We are faced with a dilemma,” says Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) , whose agency is supporting the new research. “People infected do not seem to make really good antibodies in terms of potency and breadth.”
So far, scientists have been unable to successfully induce the creation of bNAbs in humans through an HIV vaccine. This is where the cows come in.
The researchers injected four calves with HIV immunogens, which are proteins designed to elicit an immune response to the virus. They discovered that the cows very rapidly developed bNAbs to HIV in their blood.
“I was shocked,” says study author Devin Sok, the director of antibody discovery and development at IAVI . “It was really crazy and very exciting. The responses developed very quickly — between one to two months — which is well beyond what we anticipated.”
The researchers were able to isolate antibodies from the calves and took a closer look. An antibody called NC-Cow 1 was revealed to be especially powerful when it came to attacking HIV.
“The kind of insight we get from studying this is an understanding ofthe mechanisms whereby the cows’ immune system is capable of creat ing these antibodies,” says Fauci.
Understanding how an immune system effectively develops antibodies against HIV, even if it belongs to a cow, is valuable information for scientists hoping to develop an HIV vaccine, especially if they can find a way to get the human body to mimic the creation of these antibodies. The new research also provides insight into how to develop new therapies or treatments for viruses that evade the human immune system.
“As a scientist, this is really exciting,” says Sok. “To put it into perspective, the first broadly neutralizing antibodies were discovered in the 1990s. Since then, we’ve been trying to elicit these antibodies through immunization, and we’ve never been able to do it until now. Until we have immunized a cow. This has given some information for how to do it so that hopefully we can apply that to humans.”
New GOP health care bill will determine winners, losers
FILE – In this July 13, 2017 file photo, Senate Majority Leader Mitch McConnell of Ky. walks to his office on Capitol Hill in Washington. Republicans’ latest health care plan would create winners and losers among Americans up and down the income ladder, and across age groups. (Pablo Martinez Monsivais, File/Associated Press)
By Ricardo Alonso-Zaldivar | APJuly 15 at 2:36 AM
WASHINGTON — Republicans’ latest health care plan would create winners and losers among Americans up and down the income ladder, and across age groups.It would give consumers more responsibility for their insurance choices, a goal long held by conservatives who argue that’s key to a true health care market. Younger adults and healthy people in the solid middle class may find more agreeable options. But low-income people may not be able to afford coverage, along with older and sicker adults.
And there are potential unintended consequences for people with employer-provided insurance, currently about 170 million Americans. Allowing individuals to pay premiums from tax-sheltered accounts may create incentives for employers to stop offering coverage, say some independent analysts.
The legislation would put limits on federal spending for Medicaid, a partnership program with states to cover low-income people, the disabled and nursing home residents. The drawback is that state officials could eventually face no-win choices, such as having to pick between paying for coverage for low-wage working mothers and support services for elderly people trying to stay out of nursing homes.
As Senate Majority Leader Mitch McConnell, R-Ky., steers toward debate and votes next week, here is a look at some of the latest changes and major issues:
The new Senate bill incorporates the core of a proposal from Sen. Ted Cruz, R-Texas, that would reorganize the market for policies purchased by individuals. As many as 20 million Americans get coverage this way, about half through subsidized markets like HealthCare.gov, created under former President Barack Obama.
Cruz would change basic requirements that Obama’s law imposed on individual plans, including standard benefits such as pregnancy, maternity and newborn care; wellness visits and mental health treatment. The law also requires the same premium rates for sick and healthy people.
Under the Cruz approach, an insurer can offer plans that don’t comply with such requirements, provided they also offer coverage that does. The problem, say critics, is that the healthy would flock to low-premium, skimpy plans, leaving the sick to face escalating prices for comprehensive coverage.
“Healthy people would have opportunities to buy lower-premium, skinnier plans, while people with pre-existing conditions not eligible for premium subsidies could find themselves priced out of insurance,” said Larry Levitt of the nonpartisan Kaiser Family Foundation.
The latest bill includes another $70 billion to help states keep health insurance affordable for older, sicker customers. But it’s not clear how those backstops would work, and the federal funding eventually would end.
Some insurers are worried because of a technical change with huge practical implications: Health plans that enroll healthier customers would no longer have to cross-subsidize those with sicker patients, as is currently required.
“We think it is unworkable,” said Justine Handelman, top Washington lobbyist for the BlueCross BlueShield Association. She predicted skyrocketing costs for taxpayers also, stuck with the bill for sicker patients.
EMPLOYER ESCAPE HATCH?
McConnell’s new bill made a major change to tax-sheltered health savings accounts, which was also advocated by Cruz.
Under the bill, health savings accounts could be used to pay premiums with pre-tax money. Under current law, they can only be used to cover out-of-pocket costs, such as deductibles and copayments.
The change is meant to level the playing field for people buying individual plans, as compared to people getting employer coverage. The value of workplace insurance is tax-free for employees and tax-deductible for employers.
But some analysts say McConnell risks undermining workplace coverage.
The upside is that the change might encourage more self-employed people to buy individual health insurance policies. The downside is that some employers may see it as an invitation to drop health benefits, particularly since the GOP also would repeal Obama’s requirement that larger companies provide health care or face fines.
“Allowing individuals to purchase insurance with pre-tax dollars eliminates one of the advantages to employer-provided insurance,” said Elizabeth Carpenter of the Avalere Health consulting firm. “That may lead some employers to consider whether or not they want to continue to offer health insurance.”
THE POOR AND THE SICK
McConnell kept some of the Obama-era tax increases used by Democrats to finance expanded coverage. But the money will be going to shore up private insurance, not the Medicaid program. Medicaid accounts for half or more of the 20 million Americans gaining coverage as a result of the Affordable Care Act.
Medicaid covers low-income people, from many pregnant women and newborns, to disabled people and many elderly nursing home residents. The GOP bill would start by phasing out enhanced federal financing for Obama’s Medicaid expansion, adopted by 31 states. Perhaps more significantly, it would limit future federal funding for the overall program. As a result, it’s estimated Medicaid would cover 15 million fewer people by 2026.
The bill would add $45 billion to help states confronting the opioid epidemic pay for treatment and recovery. But that hasn’t swayed the American Medical Association, which points out that people in recovery also need comprehensive health insurance.
Republican governors don’t like the Medicaid cuts, and some have been vocal. About half the states that expanded Medicaid now have GOP chief executives.
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Nevada Gov. Brian Sandoval, a Republican who oversaw a Medicaid expansion, said more than 200,000 people gained coverage in his state.
“You think about 210,000 men, women and children, senior citizens, the drug addicted, the chronically ill,” Sandoval said. “These are people that used to get their treatment in emergency rooms, if they got any treatment at all. I keep going back to the fact that they are living a better quality of life.”
Associated Press writer Jennifer McDermott in Providence, Rhode Island, contributed to this report.
Copyright 2017 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
that Republican leaders released on Thursday morning seemingly has something for everyone—but perhaps not enough for anyone.
Seeking to quell a revolt from more than one-fifth of his conference, Majority Leader Mitch McConnell agreed to forego two significant tax cuts for the wealthy and instead pour hundreds of billions of dollars back into the proposal he released two weeks ago. There’s now $45 billion to combat opioid addiction and even more funding to help mitigate higher insurance costs for low-income people and to stabilize the individual markets. An additional $70 billion would go to states to help drive down premiums, on top of $112 billion that was in the original proposal. McConnell’s target was senators toward the center of the Republican ranks, who represented the largest bloc of opposition to his first legislative draft.To woo conservative critics, the majority leader added a provision based on a proposed amendment from Senators Ted Cruz of Texas and Mike Lee of Utah—backed by pressure from a number of activist groups—that would allow insurance companies to sell stripped-down, inexpensive plans that don’t conform to Obamacare’s standards as long as they offer at least one policy that does. Well, sort of. McConnell’s draft includes the Cruz-Lee idea in brackets, an indication of its polarizing and therefore precarious status within the GOP health-care debate.
McConnell needs to pick up support from both ends of the ideological spectrum. He can afford only two Republican defections, and at least 10 of his members had come out against the first version of the Better Care Reconciliation Act before McConnell abandoned plans to bring it up for a vote last month. Two of those critics, Senator Susan Collins of Maine in the center and Senator Rand Paul of Kentucky on the right, appear to have hardened in their opposition this week. Collins said it would take “a complete overhaul” to win her support, and Paul has gone on a media tour to rail against the revised proposal, saying that based on what he had heard, it was even worse than the original because it repealed less of Obamacare and included a bigger “bailout” for insurers.
Within hours after the revised draft’s release, both Paul and Collins reiterated their opposition to it an d said they would vote against even bringing it up for debate. As on the final vote, McConnell needs at least 50 Republicans to sign off on the procedural motion, and with Paul and Collins apparently out, he needs every other member of his conference to agree.
In a speech on the Senate floor after unveiling the bill to Republicans, McConnell pleaded with his colleagues to allow it at least to come up for debate. “I hope every senator will vote to open debate. Because that’s how you change the status quo,” he said. “This is our opportunity to really make a difference on health care. This is our chance to bring about changes we’ve been talking about since Obamacare was forced on the American people. It’s our time to finally build the bridge away from Obamacare’s failures and deliver relief to those who need it.”While McConnell picked quick support from several party loyalists, most of the holdouts on the original draft remained undecided. Senators Rob Portman of Ohio and Shelley Moore Capito of West Virginia said they would review the bill, as did Senator Dean Heller of Nevada, a sharp critic initially who is under intense pressure in the run-up to a reelection campaign next year. In an ominous sign for McConnell, however, Capito said in a statement she still had “serious concerns” about the proposal.
McConnell all but ignored complaints from moderates to soften the bill’s deepest and most contentious cuts—a $772 billion reduction in Medicaid spending over a decade, with hundreds of billions in additional cuts in the 10 years after that. The cuts, which include a four-year phase-out of Obamacare’s Medicaid expansion and a change in the program’s growth rate, would not begin until 2020. According to the Washington Post, McConnell told moderates to support the bill with those cuts included because they would never go into effect.
Though rather cynical, it’s an assumption held by some in Washington-based on the likelihood that Democrats will win control of the House in 2018 or the presidency in 2020 and work with Republicans to put off the Medicaid cuts.While the new bill maintains most of the Medicaid cuts, it changes the formula under which hospitals would be reimbursed for treating patients that can’t pay their bill. And it would allow states some wiggle room if a public health emergency was declared or to seek a waiver to access more funds to cover the elderly and disabled, according to a summary posted by the Senate Budget Committee.
Yet like the entire bill itself, McConnell’s Medicaid bet is a risky one. Senators like Collins, Lisa Murkowski of Alaska, Heller, Portman, and Capito have strongly opposed the cuts to Medicaid and were already frustrated with the secretive, top-down process McConnell has led on the health-care bill. And conservative activists and senators have pointed to the Medicaid changes as one of the few things they like about a proposal that does not truly fulfill their promise to repeal Obamacare. They had already stomached the Senate’s longer lead-time in ending the ACA’s Medicaid expansion, but will they recoil at McConnell’s reported admission that the reforms might not endure at all?
In another blow to Collins and Murkowski, McConnell also retains provisions blocking federal funds from going to Planned Parenthood and banning the use of subsidies to purchase plans that cover abortion. Both senators had criticized those aspects of the original bill, and if both Collins and Paul vote against the legislation as they’ve indicated, Murkowski’s opposition on those grounds could sink it entirely.
Cruz has demanded the inclusion of his Consumer Freedom Choice Amendment in the underlying Senate bill as the price for his support. But the version that McConnell included was different, Lee tweeted shortly before Republicans were scheduled to see the revised bill for the first time.
While Lee was undecided, Cruz told reporters that he would support the bill as long as his amendment stayed in and no other changes were made. His position appeared to mimic the new stance of conservative activist groups, who have conceded that Republicans can’t fully repeal the Affordable Care Act but in recent days made the adoption of Cruz’s amendment striking at its core regulations their final demand. Even Grover Norquist, the anti-tax activist who has prioritized the repeal of Obamacare’s tax increases, issued a statement signaling he was okay with McConnell’s decision to keep some of them now as long as the leadership committed to getting rid of them in subsequent tax-reform legislation. Norquist told me in an interview last month that keeping the taxes on the wealthy even temporarily was “a bad idea.”
Illustrating McConnell’s challenge in navigating the bill to passage, the changes that Cruz and Lee are demanding could solidify opposition among moderates or lose even more votes among Republicans leery of doing anything that threatens protections for people with preexisting conditions. The health-care industry is aligned against the proposal, which would essentially create separate insurance markets for sick and healthy people. Even the insurance industry’s top lobbying group, America’s Health Insurance Plans, came out in public opposition to the amendment after staying quiet through much of the Senate debate. Whether the Cruz amendment stays in the bill is in doubt. A senior GOP policy staffer said Thursday the provision was put in brackets in the bill text because “the policy is continuing to be worked on as members react to it.” Republicans have asked the Congressional Budget Office to score versions of the bill with and without the Cruz policy, but it’s unclear whether the report released next week will fully assess the amendment.
The next big test for McConnell will come early next week, when the CBO releases its analysis. The original bill fared little better with the CBO than the legislation House Republicans passed in May; the budget office found that the Senate bill would result in 22 million fewer people having health insurance after a decade. McConnell is hoping that the infusion of money into the subsidy and stabilization programs will improve that number and boost support for the bill. But if three or Republicans vote against a procedural motion to bring the proposal to the floor next week, it won’t even see a formal debate.In an indication of how dicey the revised bill’s prospects were, two Republican senators, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, chose the day of its release to unveil their own, competing idea for a partial replacement of Obamacare. Appearing on CNN before a crucial GOP meeting, they proposed a plan that would do away with Obamacare’s individual and employer mandates but keep most of its tax increases. But instead of funding a federal subsidy program, that revenue would be sent to the states so that they could craft their own health-care plans as they saw fit.
“If you like Obamacare and you want to repair it, you can,” Graham said on CNN. “If you want to replace it, you can.”
The idea is in line with an earlier proposal from Cassidy and Collins that would have allowed states to choose whether they kept Obamacare or not. That plan went nowhere, but with Republicans nearing a stalemate on health care, the senators are betting that their colleagues will give it another look.
Republican lawmakers on Thursday swiftly rebuked President Donald Trump for crudely claiming that “Morning Joe” co-host Mika Brzezinski was “bleeding badly from a face-lift,” saying such tweets are beneath the office of the president.
In a two-part tweet, Trump said he “heard poorly rated @Morning_Joe speaks badly of me (don’t watch anymore).” He then went on to hit Brzezinski: “how come low I.Q. Crazy Mika, along with Psycho Joe, came … to Mar-a-Lago 3 nights in a row around New Year’s Eve, and insisted on joining me. She was bleeding badly from a face-lift. I said no!”
The messages, some of the most graphic and personal sense Trump became president, were condemned by Republicans who are struggling to push Trump’s legislative agenda forward while the White House is consumed by the Russia probes and self-inflicted dramas.
“Obviously, I don’t see that as an appropriate comment,” House Speaker Paul Ryan (R-Wis.) said Thursday during his weekly press conference, adding, “Look, what we’re trying to do around here is improve the tone, the civility of the debate, and this obviously doesn’t help do that.”
Sen. Lindsey Graham (R-S.C.) went further, tweeting, “Mr. President, your tweet was beneath the office and represents what is wrong with American politics, not the greatness of America.”
Graham later told POLITICO that Trump’s insult was “highly inappropriate” regardless of any impact it might have on distracting from the GOP agenda. Asked if the president should apologize, Graham said, “I would, if I were” Trump.
The tweets echo some of Trump’s attacks from the campaign trail, during which he went after then-Fox News host Megyn Kelly after the first debate by saying, “You could see there was blood coming out of her eyes, blood coming out of her wherever.”
But the messages take on a new tenor now that Trump is in the Oval Office, and is trying to pull off big legislative lifts — including a Obamacare repeal bill and tax reform package — that require message discipline.
White House spokeswoman Sarah Huckabee Sanders quickly defended the tweets, explaining the president fights back when he feels the criticism toward him is unwarranted.
“Look, I don’t think that the president’s ever been someone who gets attacked and doesn’t push back,” Sanders told Fox News on Thursday morning. “There have been an outrageous number of personal attacks, not just to him but to frankly everyone around him. … This is a president who fights fire with fire and certainly will not be allowed to be bullied by liberal media or liberal elites in Hollywood or anywhere else.”
Sanders said she personally has been attacked on “Morning Joe” on matters that have nothing to do with her beliefs, ideology or policy. “I have seen far worse things [than the tweets] come out of that show,” she said.
The first lady’s office responded to the president’s tweet through a spokeswoman who reiterated what Melania Trump said in an April 2016 speech.
“As the First Lady has stated publicly in the past, when her husband gets attacked, he will punch back 10 times harder,” Stephanie Grisham, Melania Trump’s communications director, said in a statement.
But there’s evidence that the public is frustrated with the president’s Twitter use. More than 6-in-10 registered voters say Trump should stop tweeting, including 49 percent of Republicans, according to a Quinnipiac University poll conducted ahead of Trump’s latest attack and released Thursday.
And some Republicans in Congress said Trump crossed a line with his vulgar message.
Following a hearing on U.S. Capitol Police, Republican Sen. James Lankford said in a statement that the president “should model civility, honor, and respect in our political rhetoric. The President’s tweets today don’t help our political or national discourse and do not provide a positive role model for our national dialogue.”
Unlike other Republicans who in the past have vocalized their opposition to Trump’s actions, Lankford isn’t a notably frequent Trump critic.
Republican Sen. Ben Sasse, who is a frequent critic, tweeted: “Please just stop. This isn’t normal and it’s beneath the dignity of your office.”
House Minority Leader Nancy Pelosi agreed, telling reporters that what Trump tweeted was “so blatantly sexist” and “really saddens me because it is so beneath the dignity of the president of the United States to engage in such behavior.”
She also blasted her Republican colleagues who haven’t condemned the president’s rhetoric. “The Republicans, they can tolerate almost anything — a candidate beating up a reporter and then cheering him on as he arrives in Congress, the tweets of the president of the United States,” she said at her weekly news conference. “They set a low standard for public officials in terms of their demeanor.”
Trump’s tweet dominated the conversation on a day when the House was scheduled to vote on two immigration bills, the Senate was focused on getting its Obamacare repeal legislation back on track, and part of the administration’s travel ban was set to be enforced Thursday evening. The White House had also designated this “energy week,” with Trump scheduled to deliver remarks at an energy event at the Energy Department.
Republicans expressed frustration that the president’s tweets do nothing to further the GOP agenda.
Sen. Susan Collins (R-Maine), who is among the Republican holdouts on the health care bill, tweeted: “This has to stop – we all have a job – 3 branches of gov’t and media. We don’t have to get along, but we must show respect and civility.” Sen. Lisa Murkowski (R-Alaska), another skeptic of the GOP health bill, tweeted, “Stop it! The Presidential platform should be used for more than bringing people down.”
Conservative commentator Laura Ingraham sent out a tweet chastising the White House’s message discipline: “Today ALL comms coming out of WH shd be focused on #KatesLaw and #NoSanctuaryforCriminalsAct — not cable TV hosts.”
GOP strategist Rick Tyler, a former communications aide to Texas Sen. Ted Cruz’s White House bid, told POLITICO that Trump’s tweets have “zero benefit” and criticized the administration’s defense of them as “childish.”
“Republicans will arrive at the 2018 elections with absolutely no accomplishments and nothing to run on,” Tyler said. “In order to effect large-scale public policy change through legislation, you must have a communications strategy to convince the country that the direction you’re going is somewhere they’d like to go.”
While Trump’s attack on Thursday morning provoked a big response, the “Morning Joe” hosts have a notorious love-hate relationship with the president. During the 2016 campaign, Trump was a frequent call-in guest to the show and as recently as March retained Joe Scarborough’s advice on matters before addressing Congress. But the MSNBC show has also faced criticism for being too cozy with the administration.
In a Vanity Fair report from May on the co-hosts’ recent engagement, the couple acknowledged meeting with the president more than a week after his inauguration, where Trump reportedly suggested they have their wedding at Mar-a-Lago or the White House. According to Scarborough, Trump even suggested he could be the one to marry them.
Scarborough and Brzezinski have since become increasingly critical of the president, and Trump has repeatedly attacked them on Twitter, but Thursday’s messages marked a new low.
Brzezinski responded to Trump shortly after his tweets on Thursday with her own post of a Cheerios box detailing a child and the slogan “Made For Little Hands” — a seemingly pointed reference to the campaign trail during which Trump’s hand size was often targeted.
MSNBC, meanwhile, was direct and unsparing in its criticism.
“It’s a sad day for America when the president spends his time bullying, lying and spewing petty personal attacks instead of doing his job,” an MSNBC spokesperson said, echoing a similar sentiment from the organization’s spokesman Mark Kornblau, who tweeted that he “never imagined a day when I would think to myself, ‘it is beneath my dignity to respond to the President of the United States.’”
It was not immediately clear what specific comments set off the Twitter attacks this morning, but Brzezinski did hit the president this morning on “lying … and destroying the country.”
“Nothing makes a man feel better than making a fake cover of a magazine about himself, lying every day and destroying the country,” Brzezinski said in reference to a Washington Post report that alleges a fabricated Time magazine cover photo featuring Trump is hanging in at least five of his golf clubs.
Also, on Tuesday’s episode of “Morning Joe,” Brzezinski and Scarborough went back and forth on Trump’s hand size and his onslaught of media-focused tweets of late.
“That’s a very small person,” Brzezinski said.
“I work in cable news and I can tell you that’s sad, pathetic. Think bigger,” Scarborough countered, adding that while the “worst health care strategy ever” rages, Trump’s talking about the media.
“Keep on being small,” Brzezinski said.
“Tiny. That’s the word,” Scarborough corrected.
On the campaign trail, the president was often criticized for his treatment of women, most notably after the infamous “Access Hollywood” tape in which Trump can be heard bragging about sexually assaulting women.
And in a bizarre moment on Tuesday, while on the phone with Ireland’s new prime minister, Trump called forward an Irish journalist to comment on her smile.
Despite the furor around his tweets on Thursday, Trump did get some support outside of the White House.Fox News primetime host and frequent Trump defender Sean Hannity tweeted various links to “Morning Joe”-related coverage. “Maybe liberal Joe should stop calling the @POTUS a schmuck, a liar, a thug and mentally unhinged. Were they kissing @POTUS ass at xmas? Yes,” he tweeted.
Sen. Richard Shelby (R-Ala.) also appeared to defend the president, noting that he’s dealing with an adversarial news media.
“The media is salting him every day,” Shelby said. “I guess he’s fighting back.”
Other lawmakers, however, said they were trying to tune it out.
Sen. Ron Johnson (R-Wis.) said he didn’t want to talk about the president’s tweets because he’s trying to “stay positive.”
“If you don’t have something nice to say, say nothing at all,” Johnson said.
“The American people need us to be focused on health care and tax reform, not Twitter fights and cable news,” Sen. Tim Scott (R-S.C.) said on Twitter.
Former Florida Gov. Jeb Bush, who unsuccessfully ran for president in 2016, summarized Trump’s comments in three words: “Inappropriate. Undignified. Unpresidential.”
Thursday morning’s tweet storm also fits into Trump’s recently stepped-up crusade against the media in which he has targeted other outlets that he believes are publishing unfair coverage of his administration.
Trump attacked The Washington Post on Wednesday, complaining that the “fake news” newspaper was protecting Amazon from tax liabilities with its coverage.
Representatives for Brzezinski and Scarborough did not immediately respond to requests for comment.
Hadas Gold, Elana Schor, Kyle Cheney, Austin Wright, Heather Caygle and Diamond Naga Siu contributed to this report.
A vote on the Senate’s proposed health care bill has been postponed until after the July 4 recess, after a growing number of senators announced they would not support the bill in its current form, multiple outlets are reporting.
Senate Majority Leader Mitch McConnell (R-Ky.), as well as Senate Majority Whip John Cornyn (R-Texas) had been adamant that a vote on the bill would happen before the Senate recessed for Independence Day.
However that’s no longer the plan after at least four Republican Senators announced they would not vote to begin debate on the legislation.
This is a breaking news article and will be updated
(THIS ARTICLE IS COURTESY OF THE SINGAPORE NATIONAL REVIEW)
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The key is to ensure that one generation won’t bankrupt future generations by living beyond its means. Obituaries of Lee Kuan Yew, the first prime minister of Singapore who died this week at age 91, broke down into roughly two camps: He was a hero, building a “clean as Disneyland” republic that runs like a Swiss watch. He was an autocrat, who built a successful economy but crushed opponents and journalists who challenged his “managed” democracy. Both statements have big elements of truth. I take a third approach, based on a fascinating visit I made to Singapore earlier this month. Lee Kuan Yew, a member of Britain’s left-wing Labour party while a student at Cambridge, managed to create a workable welfare state, one that provides for people without creating Social Security–like Ponzi schemes or unsustainable entitlements. Both liberals and conservatives have much to learn from what he built, the details of which are missing in most of the tributes to him. Lee’s first priority when he became prime minister in 1959 was to reimagine Singapore’s economy. “Back then, this place was a swamp, with no natural resources, and it even had to import its drinking water from Malaysia,” Jim Rogers, a noted American investor who has lived in Singapore for nearly a decade, told me during my visit there. By embracing free trade, capital formation, vigorous meritocratic education, low taxes, and a reliable judicial system, Lee raised the per capita income of his country from $500 a year to some $52,000 a year today. That’s 50 percent higher than that of Britain, the colonial power that ruled Singapore for 150 years. Its average annual growth rate has averaged 7 percent since the 1970s. “A 2010 study showed more patents and patent applications from the small city-state of Singapore (population 5.6 million) than from Russia (population 140 million),” noted economist Thomas Sowell observes. But that wealth wasn’t used to create a traditional welfare state. Economist Mark Skousen notes that Singapore is rated along with Hong Kong as one of the two most free economies in the world. Any expansion of government is gradual and grudging. In 2013, when Singapore broadened its medical-benefits program, the local Straits Times newspaper made clear the government’s philosophy: “The first [priority] is to keep government subsidies targeted at those who most need them, rather than commit to benefits for all. Universal benefits are ‘wasteful and inequitable,’ and hard to take away once given, [finance minister Tharman Shanmugaratnam] said.” That mindset is embodied in Singapore’s philosophy of welfare, which rests on four pillars: Each generation should pay its own way. Each family should pay its own way. Each individual should pay his own way. Only after passing through these three filters should anyone turn to the government for help. But it will be there when needed. Singapore’s approach to the provision of health care, retirement income, and housing is in sharp distinction to that of other countries. People are required to make relatively high payments into savings plans from which they can later buy a home, pay tuition, and purchase a variety of insurance policies. For those under age 50, the employee contributes 20 percent of his income, and the employer 16 percent. A third of the employee’s share is put into a private Medisave account. When the balance reaches 34,100 U.S. dollars, any excess funds can be used for non-health-care purposes. All are enrolled in a catastrophic-health-care plan, although they can opt out. MORE LEE KUAN YEW, FATHER OF THE SINGAPORE MIRACLE LEE KUAN YEW’S GREATEST ACCOMPLISHMENT MAY NOT HAVE BEEN SINGAPORE’S ECONOMIC SUCCESS Health-care expert John Goodman is credited (along with economist Richard Rahn) with first proposing medical savings accounts in the U.S. He says Singapore shows that they can work as the backbone of a health-care system. “The issue is,” he says, “can individuals be counted on to manage their own health-care dollars responsibly, or does health care work better if all the dollars are controlled by government or insurance companies?” The answer is clear. Not only is Singapore’s population healthy, but the private sector dominates health-care spending, and consumer choice keeps health-care costs down. In Singapore, the government’s share of health-care spending has fallen to 20 percent, down from 50 percent 30 years ago. “Singapore has found a rational way to provide services that are provided by legalized Ponzi schemes in the rest of the developed world,” Goodman told me in an interview. “Those governments have made promises they must either default on or impose draconian taxes to pay for. Singapore has avoided that problem.” It’s no wonder that other countries constantly consult Singapore for guidance on how to turbo-charge their economies. In 2011, Ghana’s vice president, John Dramani Mahama, told a visiting delegation from Singapore that his country “takes a lot of inspiration from Singapore in their economic transformation from a third- into a first-world country.” There is less to emulate from Singapore’s brand of politics. As Frank Lavin, a former U.S. ambassador to Singapore from 2001 to 2005, notes: “Lee believed that open politics can lead to demagoguery, rent-seeking, and short-term thinking. Yet over time, Singapore did become more open, allowing for both political debate and contested elections. . . . Of Lee’s many successes, his most important legacy might be the move to that more open political system to complement the open economics.” But from my visit there, I believe that the least appreciated part of Lee Kwan Yew’s legacy is his method of ensuring that one generation won’t bankrupt future generations by selfishly living beyond its means. It’s a welfare state that works, and one he always said was available to any political leader with the courage to tell his people the truth about the limits of government’s power to pass out goodies. — John Fund is national-affairs correspondent for NRO.
The Affordable Care Act gave health insurance to millions of Americans by shifting resources from the wealthy to the poor and by moving oversight from states to the federal government. The Senate bill introduced Thursday pushes back forcefully on both dimensions.
The bill is aligned with long-held Republican values, advancing states’ rights and paring back growing entitlement programs, while freeing individuals from requirements that they have insurance and emphasizing personal responsibility. Obamacare raised taxes on high earners and the health care industry, and essentially redistributed that income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades.
The draft Senate bill, called the Better Care Reconciliation Act, would jettison those taxes while reducing federal funding for the care of low-income Americans. The bill’s largest benefits go to the wealthiest Americans, who have the most comfortable health care arrangements, and its biggest losses fall to poorer Americans who rely on government support. The bill preserves many of the structures of Obamacare, but rejects several of its central goals.
Like a House version of the legislation, the bill would fundamentally change the structure of Medicaid, which provides health insurance to 74 million disabled or poor Americans, including nearly 40 percent of all children. Instead of open-ended payments, the federal government would give states a maximum payment for nearly every individual enrolled in the program. The Senate version of the bill would increase that allotment every year by a formula that is expected to grow substantially more slowly than the average increase in medical costs.
Avik Roy, the president of the Foundation for Research on Equal Opportunity, and a conservative health care analyst, cheered the bill on Twitter, saying, “If it passes, it’ll be the greatest policy achievement by a G.O.P. Congress in my lifetime.” The bill, he explained in an email, provides a mechanism for poor Americans to move from Medicaid coverage into the private market, a goal he has long championed as a way of equalizing insurance coverage across income groups.
States would continue to receive extra funding for Obamacare’s expansion of Medicaid to more poor adults, but only temporarily. After several years, states wishing to cover that population would be expected to pay a much greater share of the bill, even as they adjust to leaner federal funding for other Medicaid beneficiaries — disabled children, nursing home residents — who are more vulnerable.
High-income earners would get substantial tax cuts on payroll and investment income. Subsidies for those low-income Americans who buy their own insurance would decline compared with current law. Low-income Americans who currently buy their own insurance would also lose federal help in paying their deductibles and co-payments.
The bill does offer insurance subsidies to poor Americans who live in states that don’t offer them Medicaid coverage, a group without good insurance options under Obamacare. But the high-deductible plans that would become the norm might continue to leave care out of their financial reach even if they do buy insurance.
The battle over resources played into the public debate. Mitch McConnell, the Senate majority leader, said the bill was needed to “bring help to the families who have been struggling with Obamacare.” In a Facebook post, President Barack Obama, without mentioning the taxes that made his program possible, condemned the Senate bill as “a massive transfer of wealth from middle-class and poor families to the richest people in America.”
In another expression of Republican principles, the bill would make it much easier for states to set their own rules for insurance regulation, a return to the norm before Obamacare.
Under the bill, states would be able to apply for waivers that would let them eliminate consumer protection regulations, like rules that require all health plans to cover a basic package of benefits or that prevent insurance plans from limiting how much care they will cover in a given year.
States could get rid of the online marketplaces that help consumers compare similar health plans, and make a variety of other changes to the health insurance system. The standards for approval are quite permissive. Not every state would choose to eliminate such rules, of course. But several might.
“You can eliminate all those financial protections,” said Nicholas Bagley, a law professor at the University of Michigan. “That would be huge.”
Americans with pre-existing conditions would continue to enjoy protection from discrimination: In contrast with the House health bill, insurers would not be allowed to charge higher prices to customers with a history of illness, even in states that wish to loosen insurance regulations.
But patients with serious illnesses may still face skimpier, less useful coverage. States may waive benefit requirements and allow insurers to charge customers more. Someone seriously ill who buys a plan that does not cover prescription drugs, for example, may not find it very valuable.
There are features that would tend to drive down the sticker price of insurance, a crucial concern of many Republican lawmakers, who have criticized high prices under Obamacare. Plans that cover fewer benefits and come with higher deductibles would cost less than more comprehensive coverage.
But because federal subsidies would also decline, only a fraction of people buying their own insurance would enjoy the benefits of lower prices. Many middle-income Americans would be expected to pay a larger share of their income to purchase health insurance that covers a smaller share of their care.
The bill also includes substantial funds to help protect insurers from losses caused by unusually expensive patients, a measure designed to lure into the market those insurance carriers that have grown skittish by losses in the early years of Obamacare. But it removes a policy dear to the insurance industry — if no one else. Without an individual mandate with penalties for Americans who remain uninsured, healthier customers may choose to opt out of the market until they need medical care, increasing costs for those who stay in.
The reforms are unlikely to drive down out-of-pocket spending, another perennial complaint of the bill’s authors, and a central critique by President Trump of the current system. He often likes to say that Obamacare plans come with deductibles so high that they are unusable. Subsidies under the bill would help middle-income consumers buy insurance that pays 58 percent of the average patient’s medical costs, down from 70 percent under Obamacare; it would also remove a different type of subsidy designed to lower deductibles further for Americans earning less than around $30,000 a year.
Out-of-pocket spending is the top concern of most voters. The insurance they would buy under the bill might seem cheap at first, but it wouldn’t be if they ended up paying more in deductibles.
Mr. McConnell was constrained by political considerations and the peculiar rules of the legislative mechanism that he chose to avoid a Democratic filibuster. Despite those limits, he managed to produce a bill that reflects some bedrock conservative values. But the bill also shows some jagged seams. It may not fix many of Obamacare’s problems — high premiums, high deductibles, declining competition — that he has railed against in promoting the new bill’s passage.
WASHINGTON — The 142-page Senate health care bill released on Thursday is easy to summarize: It cuts health care spending for low-income and middle-income Americans and uses the savings to finance large tax cuts for the wealthy and the medical industry.
How it accomplishes this is simple as well: It makes large cuts to Medicaid and to subsidies for private insurance, meaning large chunks of money that the government would have spent on helping Americans afford coverage, pay for long-term care and reduce their out-of-pocket costs would instead be paid either by states or by the customers themselves.
In this regard, the bill, which is called the Better Care Reconciliation Act, is broadly similar to the American Health Care Act that passed the House in May. There are some significant differences within that framework, however, especially when it comes to private insurance subsidies.
Let’s go through the main planks of the Senate plan:
Medicaid covers about 70 million Americans, including low-income residents, seniors in nursing homes (over 60 percent of whom are on Medicaid) and people with disabilities.
The Senate bill would restructure the program, cap its spending and reduce its funding significantly over time.
Protester Shares Her Reasons For Opposing Health Care Bill0:57
First, the Senate GOP bill would eliminate a major expansion of Medicaid under Obamacare.
The Affordable Care Act gave states federal funding to expand Medicaid coverage to people whose incomes were between 100 percent and 138 percent of the federal poverty line (the current cap is about $34,000 for a family of four). The Supreme Court later made the funding optional, but 30 states and the District of Columbia accepted it. The Senate bill would gradually end this expansion between 2020 and 2024.
But it would go a lot further than repealing Obamacare’s changes. It would also cap the amount of funding states can get on a per-recipient basis rather than continue the current system, in which states decide how much to spend and then have the federal government match their contribution.
Starting in 2025, the plan would then grow those per-recipient caps at a rate that’s unlikely to keep pace with increasing medical costs. A similar change in the House bill was projected to reduce Medicaid spending by $839 billion over a decade and cover 14 million fewer people. The Senate bill kicks in later, but its cuts would be even deeper than the House plan.
To make up the difference, states would either have to raise taxes, cut programs elsewhere or reduce benefits and coverage for recipients. That prospect has governors, including some Republicans like Ohio Gov. John Kasich, nervous that the reduced funding will hamper their ability to respond to health crises like the current opioid epidemic. The bill provides an extra $2 billion next year for substance-abuse treatment, a small number compared to its looming cuts.
But the Medicaid cuts also have small-government conservatives nervous. Congress has a history of passing cuts to services or tax increases and then delaying them down the line. The more time before they kick in, the greater the chance that government control might change hands or public opposition could prompt a reversal.
Private insurance subsidies
When it comes to Obamacare’s subsidies to buy private insurance, the Senate bill keeps the same basic structure, but provides less money for fewer people to purchase insurance that is less generous. These changes would also raise premiums for older people.
Under the current system, people who don’t get health insurance through work or a government program can qualify for help buying a private plan on Obamacare’s exchanges. The maximum amount you’re expected to contribute is capped based on your income.
There are limits, though. If your income is higher than 400 percent of the federal poverty line — about $98,000 for a family of four — you don’t get those subsidies. This is one of the biggest gripes about Obamacare: While most people qualify for aid, those who miss the cutoff have to pay full price, which can be difficult to afford.
The Senate bill would expand this complaint to a wider group. It would cut the subsidies off at 350 percent of the federal poverty line instead, about $86,000 for the same family. On the other hand, it would also cover some lower-income people who currently fall in the “Medicaid gap” in states that didn’t take the federal expansion.
Those who qualify for subsidies could also pay higher premiums. Under current law, no Obamacare recipients are expected to contribute more than 9.5 percent of their income in premiums. But the Senate bill changes this and make the caps more generous for younger customers and less generous for older customers. A 60-year-old making $42,000 would now have to contribute as much as 16 percent of their income to premiums.
In addition, the subsidies would be pegged to less comprehensive insurance. Under the current law, they’re calculated based on a “silver plan” that covers an average of around 70 percent of medical costs. The new bill would peg them to plans that cover only 58 percent of costs. That means higher deductibles, which have also been a major complaint among Obamacare users.
Out-of-pocket expenses would actually go up even higher for many Americans. Obamacare provided “cost-sharing reduction” payments to insurers, which they used to lower expenses for customers making up to 250 percent of the federal poverty line (about $61,500 for a family of four). For those at 150 percent of the line, these payments reduced the average deductible from $3,609 to just $255, according to the Kaiser Family Foundation. But the Senate bill ends those subsidies starting in 2019.
This is still a big difference from the House bill, which would have offered only fixed tax credits. Those credits would have likely fallen far short for many people, especially older, lower-income customers in places with high health care costs, which are often rural areas. Now the subsidies will scale up to meet the costs in their area, even if they fall short of current levels.
In addition to the subsidies, the bill provides significant funding to help stabilize insurance markets in the short-term (which have been jittery, partly due to the health care debate) and a $62 billion fund over eight years to help states potentially cover more expensive patients. But the funding is temporary, making the future uncertain.
The Senate bill does not let insurers deny people coverage based on a pre-existing condition or charge them more based on their health, which keeps two core pieces of Obamacare in place.
However, this doesn’t mean those with pre-existing conditions won’t potentially be affected. The bill does give states flexibility to waive Obamacare’s “essential health benefits,” a list of 10 broad categories of coverage every insurance plan needs.
Republicans argue states should be able to eliminate those requirements in order to lower overall premiums and provide more flexibility to insurers and customers. In the pre-Obamacare era, insurance companies often didn’t cover items like maternity care or mental health treatment, two items that are included in “essential health benefits.”
Some health experts fear that insurers will try to shepherd healthier patients into cheaper plans that cover fewer items, leaving patients with pre-existing conditions struggling to find an affordable option that covers their treatment. So even though insurers will not be able to discriminate based on pre-existing conditions, the effect could be to make their care less affordable.
Importantly, items that aren’t considered essential health benefits could be subjected to lifetime or annual limits by insurers, a practice that Obamacare eliminated.
The individual mandate
There would be no individual mandate requiring that people buy insurance, which penalized people who went without coverage.
The goal was to encourage younger and healthier people to enter the market so insurers weren’t left on the hook for only more expensive patients who were more likely to seek coverage. It didn’t work as well as intended, however, and insurers complained that the penalties were too weak and left them with a sicker crop of patients who required them to raise premiums to cover.
Schumer, Pelosi Denounce Senate GOP’s ‘Heartless’ Health Care Bill 1:19
This bill eliminates the penalties entirely, though, and instead counts on healthier people deciding coverage is affordable enough for them to get covered. That could be a problem if they conclude that the new insurance, which could have higher deductibles, is not worth the trouble.
“I just don’t see why people would sign up,” Joe Antos, a fellow at the American Enterprise Institute, told NBC News.
If they don’t come off the sidelines, or if they drop their existing coverage, premiums could rise for everyone as markets become dominated by sicker customers. The Society of Actuaries indicated in a statement on Thursday they would be watching this issue closely.
Unless you were paying a penalty for not carrying insurance, it’s unlikely you’ll notice any change in your taxes as a result of the Senate bill.
For rich people, though, the Senate bill is a nice income boost. It eliminates a surtax on income and investment gains for individuals making over $200,000 a year and married couples making over $250,000 a year. The bill also cuts taxes on health companies like medical device manufacturers and prescription drug companies.
Does it have ‘heart?’
President Donald Trump said recently that the Senate bill should be “something with heart.”
“Heart” is a subjective idea, but Trump laid out very specific standards as a candidate and as president. By those standards, the bill falls short.
Trump explicitly pledged he would make no cuts to Medicaid. Instead, the bill will cut Medicaid by hundreds of billions of dollars. He promised “insurance for everybody” backed by federal spending: Instead the bill will likely cover millions fewer people than current law. He repeatedly promised lower deductibles: Instead a core feature of the bill pushes customers towards higher deductible plans. He argued his dedication to providing more generous health care distinguished him from conservative Republicans who sought smaller government.
“This bottom line is that this bill will result in a very significant reduction in insurance coverage, as well as large increases in premium and out-of-pocket costs for those who manage to retain coverage,” Matthew Fiedler, a fellow at the Brookings Institute, told NBC News.
Should the bill become law, these will be unambiguous broken promises.
When the Republican-led Senate Rules Committee briefly flirted with the idea of restricting television interviews in the hallways of the Capitol last week, it became only the most obvious manifestation of how the party’s leaders were handling the development of a bill to overhaul Obamacare: out of the public eye.
While that effort was quickly sidelined after some outcry, the Republican leadership in the Senate was otherwise unfazed in its push to craft a bill that would expose its members to as little negative public attention as possible. No repeat of the town hall meetings that drew angry constituents who yelled at House Republicans and, they clearly hope, no weeks and weeks of swamped office phone lines.
In an article for the Monkey Cage, George Washington University’s Sarah Binder explained the four ways in which the Senate effort was unusually secretive. Sure, members of Congress would always rather pass legislation without dealing with negative criticism, but rarely have they gone so dark on such a big effort.
Here’s what’s in the new CBO report on the Republican health-care bill
The Congressional Budget Office has released its score on the revised American Health Care Act. Here’s what’s in the report. (Daron Taylor/The Washington Post)
The question that arises, though, is what Democrats could actually do about it. Binder told me that the answer was probably a simple one.
“I have a hard time seeing a real avenue for successful obstruction by the Democrats,” Binder said. The situation is unusual enough that making hard and fast predictions is tricky, she said, but “Republicans have been so aggressive on procedure here that I’d expect them to … get this through without any heed of what the Democrats were raising.”
In particular, Binder addressed a proposal outlined in a series of tweets last week by Ezra Levin, a former deputy policy director for House Democrats. Levin suggested that the Democrats could introduce an almost infinite number of amendments that would choke the Senate calendar indefinitely until they got what they wanted.
The plan hinges on the way in which the bill is being moved through the Senate. To avoid the need for Democratic votes — which the Republican majority wouldn’t get — the Obamacare replacement is being advanced using what’s known as the reconciliation process. That process involves a special set of rules that are meant to fast-track debate over the budget, but, given that it also means legislation can avoid a filibuster in the Senate, it has also been used to pass controversial bills. (Several fixes essential to the passage of Obamacare were moved using the reconciliation process, for example.)
Those rules, defined by law, include allowing only 20 hours for debate but it also includes a process called “vote-a-rama,” in which amendments may be proposed and must be voted on before the final passage of the bill. That’s where Levin’s idea comes in: He proposed introducing tens of thousands of amendments that would need to be voted on before the Senate’s bill could be passed. In theory, Levin figured, Democrats could introduce enough amendments to shut down the Senate for a year.
“In reality, that’s not going to happen,” she said. What was more likely, she said, is that someone would make a point of order that the Democrats were being “dilatory” — that is, slowing down the process unnecessarily. The presiding officer — the Republican senator on duty to manage floor debate — would be asked to rule on whether that was the case and would likely agree. Democrats could appeal the decision, but a majority vote would end the process.
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