Health Law Repeal Could Cost 18 Million Their Insurance, Study Finds

Republicans cautioned that the report painted only part of the picture — the impact of a fast repeal without a Republican replacement. Senator Orrin G. Hatch, Republican of Utah and the chairman of the Finance Committee, said the numbers represented “a one-sided hypothetical scenario.”

“Today’s report shows only part of the equation — a repeal of Obamacare without any transitional policies or reforms to address costs and empower patients,” he said. “Republicans support repealing Obamacare and implementing step-by-step reforms so that Americans have access to affordable health care.”

Congress last week approved a budget that clears the way for speedy action to repeal the health care law. The votes were 51 to 48 in the Senate and 227 to 198 in the House.

But Republicans have yet to agree on a replacement bill, and existing Republican plans, like one drafted by Representative Tom Price of Georgia, who was selected as Mr. Trump’s secretary of health and human services, have yet to be scrutinized by the budget office. The office provides Congress with the official projections of legislative costs and impact that lawmakers use to formulate policy.

In 2026

59 million

Before A.C.A.

57 million

2 years later

54 million

After Medicaid expansion and marketplace subsidies go away.

1 year later

44 million

After penalties associated with the individual mandate go away, and some insurers leave the market.


26 million

Here’s how much the number of uninsured could rise if major portions of the health law were repealed today, according to a new study.

In 2026

59 million

Before A.C.A.

57 million

2 years later

54 million

After Medicaid expansion and marketplace subsidies go away.

1 year later

44 million

After penalties associated with the individual mandate go away, and some insurers leave the market.


26 million

Here’s how much the number of uninsured could rise if major portions of the health law were repealed today, according to a new study.

“No wonder President-elect Trump realizes that repeal without replace is the real disaster,” said Senator Chuck Schumer of New York, the Democratic leader. “No wonder he has admonished the Congress not to do plain repeal.”

Republicans now have two powerful reasons to “repeal and replace” together: They hope to protect about 20 million Americans who have gained coverage under the law. And they want a politically acceptable judgment from the Congressional Budget Office on the effects of their alternative.

Mr. Trump’s statement last week that a replacement plan should go hand in hand with repeal efforts had already ignited a sense of urgency among Republicans on Capitol Hill. Over the weekend Mr. Trump said he was close to completing a plan to replace the Affordable Care Act with the goal of “insurance for everybody,” but congressional aides said Tuesday that they had not seen an actual proposal.

Republican congressional leaders are trying to put together a plan that could pass muster with the Trump team and also win approval in the Senate under fast-track procedures that would neutralize the threat of a Democratic filibuster.

House Speaker Paul D. Ryan and Senator Mitch McConnell of Kentucky, the Republican leader, met last week with Mr. Price to hash out alternatives, and they have been in close contact with the relevant committee leaders and staff members to begin hammering out ideas that could come into relief at the end of the month, when Republicans have their annual policy retreat.

Stephen Miller, a former Senate press aide and the incoming senior White House adviser for policy, who has been particularly aggressive in presenting himself as the voice of Mr. Trump on all policy matters, has pushed the notion that a plan should move quickly and in tandem with a replacement measure, rather than in a series of smaller bills, congressional aides said.

The repeal legislation analyzed by the budget office would have eliminated tax penalties for people who go without insurance. It would also have eliminated spending for the expansion of Medicaid and subsidies that help lower-income people buy private insurance. But the bill preserved requirements for insurers to provide coverage, at standard rates, to any applicant, regardless of pre-existing medical conditions.

“Eliminating the mandate penalties and the subsidies while retaining the market reforms would destabilize the nongroup market, and the effect would worsen over time,” the budget office said.

The office said the estimated increase of 32 million people without coverage by 2026 resulted from three changes: About 23 million fewer people would have coverage in the individual insurance market. Roughly 19 million fewer people would have Medicaid coverage. And there would be an increase in the number of people with employment-based insurance that would partially offset those losses.

The estimates by the budget office are generally consistent with projections by the Obama administration and by insurance companies.

In its report, the budget office said that repealing selected parts of the health care law — as specified in the earlier Republican bill — would have adverse effects on insurance markets.

In the first full year after the enactment of such a bill, the office said, premiums would be 20 percent to 25 percent higher than under current law.

Repealing the penalties that enforce the “individual mandate” would “both reduce the number of people purchasing health insurance and change the mix of people with insurance,” as younger and healthier people with low health costs would be more likely to go without insurance, the budget office said.

The Republican bill would have eliminated the expansion of Medicaid eligibility and the subsidies for insurance purchased through Affordable Care Act marketplaces, after a transition period of about two years.

Those changes could have immediately increased the number of uninsured by 27 million, a number that would gradually increase to 32 million in 2026, the budget office said.

Without subsidies, the budget office said, enrollment in health plans would shrink, and the people who remained in the individual insurance market would be sicker, with higher average health costs. These trends, it said, would accelerate the exodus of insurers from the individual market and from the public marketplaces.

As a result, it said, about half of the nation’s population would be living in areas that had no insurer participating in the individual market in the first year after the repeal of marketplace subsidies took effect. And by 2026, it estimated, about three-quarters of the population would be living in such areas.

While writing the Affordable Care Act in 2009 and 2010, lawmakers continually consulted the Congressional Budget Office to understand the possible effects on spending, revenue and insurance coverage. The current director of the budget office, Keith Hall, who signed the report issued on Tuesday, was selected and appointed by Republican leaders of Congress in 2015.

The latest report was requested by Mr. Schumer and two other Democrats, Senators Ron Wyden of Oregon and Patty Murray of Washington.

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Fear Spurs Support for Health Law as Republicans Work to Repeal It

With their quick strike on the law in the first days of the new Congress, Republicans had hoped to begin the repeal process before a backlash could develop or opposition could be organized. But congressional Republicans are at risk of losing the message war, especially since they are fighting on two fronts.

On one side, the president-elect has repeatedly lobbed disruptive demands at them, such as his insistence that they prepare a replacement health bill almost immediately. To that, he added a new promise over the weekend: that the Republican version would provide “insurance for everybody.”


Health care activists rallied on Friday near Trump Tower in Midtown Manhattan. Credit Drew Angerer/Getty Images

On the other front, Democratic lawmakers have taken to quoting grateful constituents to personalize what can be an arcane legislative fight: Bryce in Seattle; Randy in Rhinelander, Wis.; Nicole in Hockessin, Del.; and many more. The focus of public attention appears to be shifting from the well-documented defects of the health care law to the plaintive pleas of people terrified of losing insurance if the law is repealed.

“I want to thank President Obama from the bottom of my heart because I would be dead if it weren’t for him,” Jeff Jeans, a small-business man from Sedona, Ariz., who described himself as a lifelong Republican, told Speaker Paul D. Ryan on Thursday at a town-hall-style meeting televised on CNN.

Republicans acknowledge their constituents’ concerns, but they say supporters of the health law are manufacturing them. Representative Rob Woodall, Republican of Georgia, blamed Democrats for “amping up anxiety” with “fear mongering.”

“The anxiety is real,” Mr. Woodall said, “but it’s real based on the failures of the president’s health care law.”

Republicans will soon face a new challenge: maintaining anger at “Obamacare” without Mr. Obama in the White House to stir their passions.

Regardless of its provenance, the law’s support has until now received less attention. Appearing on the NBC News program “Meet the Press” five days after Mr. Obama signed the Affordable Care Act in 2010, Senator Chuck Schumer, Democrat of New York, predicted that as people learned about the law, “it’s going to become more and more popular.”

Around 20 million Americans have gained coverage through the Affordable Care Act’s online insurance marketplaces or through its expansion of Medicaid, and enrollment has continued to grow. About 11.5 million people have signed up for marketplace plans or had their coverage automatically renewed for this year, nearly 300,000 more than at this time last year, the Obama administration said this month.

But the popularity bounce never came. Public opinion remains deeply divided, with the law no more popular today than when it was passed. In December, according to a monthly tracking poll by the Kaiser Family Foundation, 46 percent of Americans had unfavorable views of the law, up from 40 percent in April 2010. The share with favorable views slipped to 43 percent, from 46 percent in April 2010.

“In the short term, the A.C.A. has been a political disaster for President Obama and the Democrats,” Dr. Ezekiel J. Emanuel, a health policy adviser in the Obama White House from 2009 to 2011, said in a 2014 book.

As Congress took a first step last week toward rolling back Mr. Obama’s signature domestic achievement, Mr. Trump celebrated. “The ‘Unaffordable’ Care Act will soon be history!” he said on Twitter.

Some Democrats distanced themselves from the Obama administration after crashed on its debut in 2013. More recently, with premiums soaring and insurers defecting from the Affordable Care Act marketplace in many states, Democrats were hard put to defend the law, which was passed without any Republican votes.

But as Mr. Trump and congressional Republicans race to repeal the law, Democrats are taking a more aggressive stance.

Senator Debbie Stabenow, Democrat of Michigan, told the story of Sonja L. Podjan, a 55-year-old blueberry farmer in Watervliet, Mich., who was in pain for several years until she got insurance under the Affordable Care Act, which covered the cost of surgery to repair a severe tear in the meniscus of her right knee.

In an interview, Ms. Podjan said she “started freaking out” after the election and sent an email to Ms. Stabenow. She said she was “flabbergasted” when she heard back from the senator’s office.

Ms. Podjan said that the premium for an insurance policy covering her and her husband was about $1,000 a month, but that they paid just $62 after receiving government subsidies provided under the law.

“I am scared to death we will lose our insurance, and what happens then?” said Ms. Podjan, who reported that she and her husband had medical expenses totaling $41,000 in the past two years.


Demonstrators at a rally in support of the Affordable Care Act on Sunday in Denver. Credit Chris Schneider/Agence France-Presse — Getty Images

Senator Tom Udall, Democrat of New Mexico, told the story of a constituent, Kevin Kargacin, whose daughter Amber takes drugs costing more than $60,000 a year for multiple sclerosis. “Kevin is scared because the cost of treating Amber’s disease is so high,” Mr. Udall said.

In an interview, Mr. Kargacin said he wrote to Mr. Udall because “we are terrified that without the Affordable Care Act, Amber could be denied insurance or run into lifetime caps on expenditures for her treatment.”

Senator Amy Klobuchar, Democrat of Minnesota, said: “Many Minnesotans have contacted me in the last few months, frightened about the future of their health care coverage. I heard from a man in Orono. His wife was diagnosed with cancer this year. On top of everything his family is now dealing with, he is terrified that his family will lose coverage if there is a repeal.”

Whether such concerns reflect a change in public opinion is difficult to say. Over the past six years, Republicans have collected stories from hundreds of constituents complaining that their insurance policies were canceled, their premiums have shot up and their deductibles are so high that the insurance is nearly worthless.

“Scott from Hickory has had his health insurance canceled three times now, disrupting his continuity of care,” said Representative Virginia Foxx, Republican of North Carolina. “Patricia from Kernersville now has a whopping $6,550 deductible.”

Representative Pat Tiberi, Republican of Ohio, reported that a constituent named Kimberly had difficulty obtaining treatment for a brain tumor because, she said, “virtually no doctors take the marketplace insurance.”

The differing accounts are not necessarily in contradiction. Some people have benefited from the law while others have seen their coverage disrupted.

Republicans said the Obama administration had been slow to recognize and acknowledge problems with the Affordable Care Act. Administration officials said insurance rate increases of 25 percent or more were not a significant problem because low-income people could get subsidies to help defray the cost — even though millions of people buying insurance on their own do not receive subsidies.

The administration insisted that insurance markets were “stable and vibrant” even as large insurers pulled out of Affordable Care Act exchanges where they were losing hundreds of millions of dollars. In 2015, the administration said that “claims data show healthier consumers” in the exchanges, but some insurers disputed that assessment, saying they had not seen an influx of healthy people to help cover the costs of sick people.

Correction: January 16, 2017

Because of an editing error, an earlier version of this article misstated the day on which the town-hall-style meeting with Speaker Paul D. Ryan was held. It was Thursday, not Friday.

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Global Health: How the Response to Zika Failed Millions

The Rio Olympics went ahead without spreading the virus, and new diagnostic tests for Zika were swiftly designed and deployed. Scientists are moving ahead with multiple vaccine candidates and new ways to fight mosquitoes without pesticides.

But the positives were counterbalanced by many negatives, experts said. They harshly criticized the partisan bickering that delayed a Zika-funding bill in Congress for months, and they decried the failure of every city in the hemisphere — other than Miami — to control mosquitoes.

Most praised the W.H.O. for declaring an emergency on Feb. 1, but also condemned as premature its decision to end it on Nov. 18.

But the greatest failure, all agreed, was that while tourists were warned away from epidemic areas, tens of millions of women living in them — many of them poor slum dwellers — were left unprotected.

As a result, a wave of brain-damaged babies is now being born. Their families are already suffering, and their medical care will eventually cost hundreds of millions of dollars.

The failure to advise women to postpone pregnancy, if they could, until the epidemic passed “was the single greatest travesty of the epidemic,” said Amir Attaran, a professor of law and medicine at the University of Ottawa.

It was “hideously racist hypocrisy,” he added. “Female American tourists were given the best and safest public health advice, while brown Puerto Rican inhabitants were told something else entirely.”


A health worker carrying insecticide that being used to try to kill mosquitoes in Sao Paulo, Brazil this month. Credit Paulo Whitaker/Reuters

Politics Got in the Way

Impoverished Latin American and Caribbean women were badly served in many ways, other experts said.

Trucks sprayed pesticides that often did not work. Admonitions from on high to wear repellent and long sleeves were given with no studies proving that they could protect indefinitely.

And health authorities, fearful of offending religious conservatives, never seriously discussed abortion as an alternative to having permanently deformed babies — even in countries where abortion is legal.

That reluctance created an unusual gulf between official advice and actual practice. Many gynecologists interviewed said privately that they offered abortions to patients whose ultrasound scans showed abnormally small heads or brain damage.

But they did so without official support or guidance from the W.H.O. or the Centers for Disease Control and Prevention.

During the epidemic, when health officials were asked why they did not advise delaying pregnancy or seeking abortions, they said that to do so would interfere with women’s reproductive rights or prevent older women from conceiving in time to have children.

At the W.H.O., Dr. Bruce Aylward, head of the Zika emergency response, called pregnancy “a complicated decision that is different for each individual woman.”

Dr. Thomas R. Frieden, director of the C.D.C., said he followed the advice of Dr. Denise J. Jamieson, chief of the agency’s women’s health and fertility branch, who said it was “not a government doctor’s job to tell women what to do with their bodies.”

Dr. Gostin said he felt the agencies had been too cautious, out of fear of criticism from women’s groups.

“Public health ought to trump that,” he said. “Giving women advice is very different from controlling women.”

Michael T. Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, gave a blunter explanation for the shyness from officials.

“The C.D.C. always gets in trouble with Congress when it talks about contraception or bullets,” he said. (By the latter, he meant that it was hard for the officials to point out that gunshots are a major cause of American deaths for fear of offending the gun lobby.)

“And abortion?” he added. “You talk about third rails in politics? Abortion is the fifth rail. They can’t touch it. If the C.D.C. had pushed the envelope any farther, its funding would have been at risk.”

C.D.C. guidance on Zika was “a little coy,” agreed Dr. William Schaffner, chairman of preventive medicine at Vanderbilt University Medical School.


Paulo Sergio with his 6-month-old son, who was born with microcephaly in Rio de Janeiro, Brazil. Credit Vanderlei Almeida/Agence France-Presse — Getty Images

“A recommendation to put off pregnancy until the risk abated should have been front and center — and much more explicit.”

Brazil, by far the hardest-hit country in the epidemic, really let its women down, said Dr. Artur Timerman, president of the medical society for dengue and arbovirus specialists there.

“For religious concerns, we have a lot of restrictions regarding advising women on birth control, so we were very far from giving them correct information,” he said. “I think we will have a lot of women infected yet, as we see lower levels of awareness.”

Missed Opportunities

Experts praised the C.D.C. for its work on developing new Zika tests and getting them to state laboratories quickly. Better antibody tests that identify past infections are still needed.

Most countries did not focus enough on preventing sexual transmission, experts said. Even New York City, which has a respected health department, filled its subways with posters showing big mosquitoes.

Yet not one of the nearly 1,000 cases diagnosed there by year’s end was transmitted by a local mosquito; all were either picked up elsewhere or transmitted sexually.

The number of children damaged by the epidemic is still unknown, but is likely to ultimately run into the tens of thousands across the hemisphere. As of the end of 2016, the W.H.O. had recorded more than 2,500 cases of Zika-related microcephaly in 29 countries.

Studies suggest that microcephaly — which results in an abnormally small head — represents only a small fraction of the damage done. Babies are being born blind, deaf or with rigid limbs or frequent seizures, and it seems likely that many more will eventually have learning and emotional problems.

The epidemic also showed that most nations remain inept at mosquito control.

“Miami is the one place that responded effectively,” said Duane J. Gubler, an expert in mosquito-borne diseases at the Duke-NUS Medical School in Singapore. “Others were mediocre or poor.”

Miami used both aerial and ground spraying of insecticide and larvicide, along with teams going house-to-house looking for breeding sites.

The Zika scare made pest-control officials and local residents more willing to test new technologies, including releasing male mosquitoes that pass on a life-shortening gene and female mosquitoes carrying bacteria that suppress their ability to transmit viruses.

A Dangerous Disconnect

Experts in Brazil, where the epidemic started, said doctors there acted quickly but were often thwarted by the country’s political and economic chaos — President Dilma Rousseff was ousted in August — or by hesitant foreign scientists.

“Brazil reacted with seriousness and foresight,” said Dr. Albert I. Ko, a Yale epidemiologist who has also worked in Salvador, Brazil, for many years. “The people in the trenches, the city and state public health officials, should be regarded as heroes.”

Why scientists are worried about the growing epidemic and its effects on pregnant women, and how to avoid the infection.

Both he and Dr. Ernesto T. A. Marques Jr., an infectious disease specialist at the University of Pittsburgh and at the Oswaldo Cruz Foundation in Brazil, said Brazilian scientists felt let down when they looked for outside help — at first from European donors and health agencies.

“The local researchers’ role was mainly to collect samples,” Dr. Marques said bitterly.

The C.D.C.’s initial reluctance to accept Brazilian scientists’ work also slowed the international response, said Dr. Peter J. Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine.

Even when the Brazilians found Zika virus in two women’s amniotic fluid and in the brain of a microcephalic fetus, “The C.D.C. would not accept it until they had done it themselves,” he said. “I saw that as hubris.”

The news media, for once, got relatively high marks from the experts — or at least higher marks than it did in the 2014 Ebola epidemic or the 2009 swine flu pandemic.

Three years ago, pictures from Africa showing men in spacesuits carrying dead bodies exaggerated the risk of Ebola to America, they said. By contrast, pictures of tiny-headed babies made Americans take Zika seriously but sensibly.

“In Brazil, the press was the first to sense that something was going on,” said Dr. Karin Nielsen, a pediatrician at the David Geffen Medical School at the University of California, Los Angeles, who also works in Rio. “It was pushing it even before the medical specialists were.”

The North American media, several experts said, did a good job debunking various myths that arose early in the epidemic, such as rumors blaming microcephaly on genetically modified mosquitoes, larvicide in drinking water or vaccines.

In Brazil, those rumors diverted attention for precious weeks, even prompting some cities to stop fighting mosquitoes temporarily.

Experts also felt scientific collaboration often faltered. For example, plans announced in February to gather 5,000 Zika-infected women into one study never materialized.

One big question remains: Will the virus return?

That is unknowable, most experts said, because no studies show how many people are now immune through previous infection.

Some Brazilian cities, including São Paulo, have not had big outbreaks and may be due for one, said Dr. Scott C. Weaver, a virologist at the University of Texas Medical Branch in Galveston who was one of the first to predict that Zika was likely to strike the Americas. So might Bolivia, Paraguay and Uruguay.

More than half of Puerto Rico’s population is probably still vulnerable, so Zika may flare up again, as it might anywhere along the Gulf Coast outside Miami.

“And even if Zika’s not bad next year,” Dr. Weaver said, “without a vaccine, these viruses are going to come and go.”

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On Washington: ‘Repeal and Replace’: Words Still Hanging Over G.O.P.’s Health Care Strategy

The uncertainty has reignited the fight to define the health insurance program in the public mind, with Republicans and Mr. Trump painting it as a disaster, and Democrats portraying it as a success that provides security to millions of Americans, many of them Trump voters. Democrats have latched on to their own catchphrase, warning that repealing the law will “Make America Sick Again” — a twist on the Trump campaign’s “Make America Great Again” theme.


The notecard on which Josh Holmes, then a top communications adviser to Mr. McConnell, first wrote the “repeal and replace” slogan for the Republican strategy in opposition to the Affordable Care Act.

Republicans have derided the Democratic message — personally developed by Senator Chuck Schumer of New York, the new Democratic leader — as trite and ineffective. But Democrats like it and believe that it goaded Mr. Trump into a more direct and complicating role in the Republican deliberations over how quickly to propose a replacement for the health care program.

They say Republicans are still relying on Mr. Holmes’s years-old brainchild because they are groping for a replacement with their new unified government days away. Democrats see the confusion as a victory in their push to thwart repeal or slow it down while wringing all the political advantage they can from the attempt.

After a series of late-night Senate budget votes that laid the procedural groundwork for repeal with no certainty on what was to follow, one Democrat delivered a new punch line.

“This is called repeal and run,” Senator Claire McCaskill, Democrat of Missouri, said on Twitter as the Senate was voting. “Chaos is coming.”

Mr. Trump’s involvement has muddled the issue further as he and Republican leaders in Congress have offered differing timetables for when a Republican alternative might be unveiled, underscoring again how difficult it can be to push through an agenda even for a party that controls all the levers of government.

The origin story of the “repeal and replace” mantra is also a reminder of how pivotal strategic messaging has been throughout the health care debate. It has produced some of the more memorable political lines in recent years, from “death panels” to “If you like your health plan, you can keep your health plan” to “Obamacare” itself. After Republicans began throwing that term around as a pejorative, Mr. Obama embraced it.


Senator Chuck Schumer of New York, the Democratic leader, during a news conference this month in Washington on Republican attempts to repeal the health care law. Credit Zach Gibson/Agence France-Presse — Getty Images

Even before landing on “repeal and replace,” Republicans scorched Democrats with buzzy phrases. In his book “The Long Game,” Mr. McConnell recounted how he instructed his legislative experts to identify special provisions that had been added to the health bill to win over wavering Democrats.

His communications staff would then “brand” these legislative sweeteners with catchy but disparaging nicknames to build opposition and public distrust for the law. The result: the “Louisiana Purchase,” “Gator Aid” and the memorable “Cornhusker Kickback,” to tarnish provisions inserted to woo senators from Louisiana, Florida and Nebraska.

“In some ways, we were enjoying ourselves,” Mr. McConnell acknowledged in his book.

The same communication strategists who originated those terms were brainstorming on March 22, 2010, while Mr. Holmes jotted ideas on a notecard. When he hit on “repeal and replace,” the McConnell team decided it had what it needed. The big question was whether they could get lawmakers to embrace it. That answer would come quickly.

“I think the slogan will be ‘repeal and replace,’ ‘repeal and replace,’” Mr. McConnell told reporters the next day. “No one that I know in the Republican conference in the Senate believes that no action is appropriate.”

Mr. Holmes said a turning point came shortly after, when Representative Mike Pence of Indiana, who was then in charge of political messaging for House Republicans, and is now the vice president-elect, latched on to the phrase. That caused conservative resistance to the “replace” aspect of the debate to evaporate.

Mr. Holmes acknowledged that he had to create only the phrase, not the actual replacement.

“I don’t do policy,” he said with a laugh.

But Republican lawmakers and leaders of the new administration do have to do policy. And they may need to do it fast if they are going to assure Americans that they intend to fulfill their seven-year-old promise to not just repeal the law, but also replace it.

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Well: How Do You Die of Parkinson’s Disease?


Credit Stuart Bradford


How do you die of Parkinson’s disease?


Parkinson’s disease, a chronic, progressive movement disorder characterized by tremors and stiffness, is not considered a fatal disease in and of itself, though it may reduce life expectancy by a modest amount. It is often said that people die “with” Parkinson’s rather than “of” the disease.

“People who are healthy when diagnosed will generally live about as long as other people in their age cohort,” said James Beck, the vice president for scientific affairs at the Parkinson’s Disease Foundation, which is involved in research, education and advocacy. “It is not a death sentence.”

Since Parkinson’s generally affects people later in life — patients are typically given a diagnosis in their 60s — patients often die of unrelated age-related diseases like cancer, heart disease or stroke. But the most common cause of death in those with Parkinson’s is pneumonia, because the disease impairs patients’ ability to swallow, putting them at risk for inhaling or aspirating food or liquids into their lungs, leading to aspiration pneumonia.

Since Parkinson’s also impairs mobility and balance, those with the disease are also at high risk for falls and accidents, which can trigger a cascade of medical problems, including being bedridden and developing pneumonia, Dr. Beck said. In its advanced stages, the disease can make walking and talking difficult and cause other problems not related to movement, including cognitive impairment. Patients often cannot care for themselves and need assistance carrying out simple activities of daily living.

One long-term study followed a group of 142 Parkinson’s patients after they were given their diagnosis; their mean age at diagnosis was around 70. The researchers found that 23 percent were generally doing well 10 years later, meaning they could maintain their balance and did not have dementia. But over half of the patients in the original group had died, with the most common cause related to Parkinson’s being pneumonia. The probability of losing one’s ability to maintain balance after 10 years was calculated to be 68 percent, and the probability of developing dementia was around 46 percent.

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Senate Takes Major Step Toward Repealing Health Care Law

The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.

The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.

Republicans say the 2016 elections gave them a mandate to roll back the health care law. “The Obamacare bridge is collapsing, and we’re sending in a rescue team,” said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. “Then we’ll build new bridges to better health care, and finally, when these new bridges are finished, we’ll close the old bridge.”

Interactive Graphic

Peeling away pieces of the law could lead to market chaos.

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Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.

On Wednesday, Mr. Trump said he would offer his own plan to repeal and replace the law “essentially simultaneously.” He said he would put forth the plan as soon as his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed.

The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. More than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law’s health exchanges.

The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.

Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date.

“We understand that everyone here understands the importance of doing it right,” he said. He described the Jan. 27 date in the budget blueprint as a placeholder.

Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: “This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might.”

The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.

A vote on the measure in the House could come on Friday.

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.

In the parlance of Capitol Hill, many of the Democrats’ proposals were “messaging amendments,” intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.

As the Senate plowed through its work on Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans.

“This is our opportunity to keep our campaign promise,” said Senator Roger Wicker, Republican of Mississippi. “This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences.”

Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, “we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution.”

Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.

Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time.

“But I don’t see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,” she said. “I just don’t see that as being feasible.” (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)

As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next.

The Senate Democratic leader, Chuck Schumer of New York, called the Republicans’ repeal plan “irresponsible and rushed” and urged them to halt their push to unravel the law.

“Don’t put chaos in place of affordable care,” he said.

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Global Health: Study Finds Lower, but Still High, Rate of C-Sections in China

China’s extraordinarily high rate is a result of its former one-child policy, changing medical care conditions and its increasingly capitalist economy.

According to the study’s authors, many parents and grandparents demand C-sections to assure that births take place on a lucky day in the astrological calendar, or because they believe that a surgically removed infant is more likely to be perfectly formed.

More than 99 percent of all women in China now give birth in hospitals — 30 years ago, only about half did. But they typically have gone through labor in open wards with no husband or family present, too few nurses and no pain relief. C-sections are an attractive alternative, said Dr. Susan C. Hellerstein, a Harvard Medical School obstetrician and one of the authors.

Doctors made more money from fees and “tips” from families if they operated, the researchers found. And if they performed scheduled surgeries rather than risk vaginal births, doctors felt they were less likely to be accused of malpractice, which is a criminal offense in China, or to face angry families demanding compensation.

Vaginal births can quickly go wrong if, for example, the cord wraps around the baby’s neck.

The study was led by doctors from China’s national statistics office, Peking University, Harvard Medical School and New York University’s Wagner School of Public Service.

The 2010 W.H.O. survey erred by relying on figures from just 21 hospitals, mostly in cities, said Dr. Jan Blustein, a health policy specialist at N.Y.U. and co-author. The new study tallied 90 percent of the country’s births over seven years.

While a few cities like Shanghai had astronomical rates, half of all Chinese still live in rural areas where home births are more common and distances to hospitals are greater, so actual rates are closer to the ideal 10 to 20 percent range.

In Tibet, however, C-sections are so rare that mothers and children who could be saved from death are undoubtedly not getting the operations, Dr. Hellerstein said. C-sections save lives in breech or multiple births, for example, or when a mother has dangerously high blood pressure or a fetal heartbeat fails.

But babies born by C-section are more likely to hospitalized for breathing problems and more likely to suffer asthma and obesity later in life, possibly as a result of not getting microbes present in the birth canal. Mothers who have had C-sections also are more likely to hemorrhage or to have a uterine rupture in the next pregnancy.

Since 2009, China has been trying to control medically unnecessary cesareans by educating patients, doctors and midwives, and by warning individual hospitals when their rates are too high, said Dr. Jianmeng Liu, director of the Office for National Maternal and Child Health Statistics of China and a study co-author.

China’s C-section rate, the authors noted, is close to that of the United States, where it is slightly over 32 percent.

That rate is higher than it should be, and higher than in many European countries, the authors said. Some mothers choose C-sections to avoid labor pains, they said, and too many doctors suggest them for convenience and for fear of facing malpractice suits.

In 2015, China ended its longstanding one-child policy, allowing two per couple.

“All these older women wanting a second baby after a C-section is going to be a big challenge,” Dr. Hellerstein said.

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Global Health: Petroleum Jelly May Reduce Risk of Eczema


Moisturizing babies’ skin everyday lowered their risk of developing the itchy, dry, scaly patches, above, that characterize eczema. Credit BSIP/UIG, via Getty Images

Applying inexpensive petroleum jelly to a new baby daily for the first six months of life may reduce the risk that the infant will develop eczema, which can be a lifelong torment, according to a new analysis.

Two studies done in newborns with relatives suffering from atopic dermatitis, the most common form of eczema, showed that rubbing moisturizer into their skin daily lowered their risk of developing the itchy, dry, scaly patches on their heads, arms and legs that characterize the disease.

Scientists at Northwestern University Feinberg School of Medicine looked at seven common moisturizers and decided that petroleum jelly was the cheapest effective one; sunflower oil came in second.

Eczema affects over 10 percent of American children, and is more common in those with dark brown skin. Its prevalence in Africa is unknown, but anecdotally it is thought to be increasing there too.

The cause is also unknown, but it is often associated with allergies and with asthma, which is also more common among African-American children, and can be fatal. Itchiness often keeps children from sleeping, and scratching can lead to skin infections. Some poor families spend large sums on expensive creams to fight the disease. The study’s authors argued that health insurance should cover moisturizers.

The theory is that moisturizers “seal” a baby’s skin against some invader that triggers inflammation.

Bigger studies that last beyond infancy must be done to prove the concept, said Dr. Steve Xu, a dermatologist at the Feinberg School and lead author of the analysis published by JAMA Pediatrics last month. But, he said, the risk of moisturizing is minimal.

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Global Health: Easing the Toll of Sickle Cell Disease in Childbirth


Sickle cell anemia in human blood. Credit Science Source

Creating hospital teams devoted to treating pregnant women who have sickle cell disease reduced death rates for those women by almost 90 percent, a study at a major hospital in Ghana showed.

Sickle cell disease is common in West Africa, and among black people in the Americas whose ancestors came from West Africa. It is caused by a genetic mutation that if inherited from only one parent protects against malaria, but if inherited from both parents can be lethal. Red blood cells can collapse into curved “sickle” shapes and clump together to jam capillaries, sometimes causing excruciating pain, shortness of breath and death.

At the Korle-Bu Teaching Hospital in Accra, the capital of Ghana, women with sickle cell disease were about 12 times as likely to die in childbirth as women without it, according to a study presented last month at the American Society of Hematology.

To overcome that, the hospital formed teams of nurses, obstetricians and blood and lung specialists and assigned them to care for all pregnant women with the disease. If the women suffered serious pain or breathing crises, and when they began labor, they got beds in two wards overseen by the team.

With help from an American team led by Dr. Michael R. DeBaun, a pediatric hematologist who directs the Vanderbilt-Meharry Center for Excellence in Sickle Cell Disease, Korle-Bu adopted proven care protocols. Those included giving transfusions before cesarean sections and treating women experiencing chest pain by having them take deep breaths and blow hard, which helps prevent lung collapse.

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