What’s in the Paris Agreement anyway?

I’m so tired ya’ll

There’s a lot of misinformation out there about what the Paris Agreement is, what it obligates the United States to, and what it obligates countries like China and India to. So let’s take a look at this landmark agreement for ourselves.

There is a PDF version of this agreement in English hosted on the UN Climate Change Newsroom website if you want to read along at home. As always, I’m not a lawyer or a politician, just doing my best to understand the law.

The Paris Agreement


The agreement begins with a preamble about who the signers are and why they’re signing. The agreement was signed by countries who are parties to the UN Framework Convention on Climate Change (AKA The Earth Summit), which basically means the 154 countries who met in 1992 and agreed that climate change was a problem. It mentions the Durban Platform, a group of negotiations which resulted in this agreement. It mentions the objectives of the Convention, including common goals yet different responsibilities. It mentions the “urgent” need for an “effective and progressive response”; it mentions the needs of developing countries who will suffer greatly from climate-change related flooding, but it tempers that with their lack of funding and technology. It mentions that signers may suffer due to the affects to prevent climate change as well as by the effects of climate change, and it keeps in mind the desire to eradicate poverty. It also brings up food insecurity and the desire to end hunger, noting that climate change may cause famines. It mentions the desire to create new jobs. It brings up a whole host of other concerns that have to be kept in mind:

  • human rights,
  • the  right to health care,
  • the rights of indigenous peoples, migrants, children, persons with disabilities, and vulnerable persons
  • gender equality
  • empowerment of women
  • intergenerational equity
  • biodiversity
  • education
  • public access to education
  • cooperation at all levels of the government

And finally, it suggests that more developed countries take the lead in this effort.

Articles 1-3

Article 1 just contains some definitions.

Article 2 says that the purpose of this agreement is to strengthen the global response to climate change. It outlines the goals: hold the increase in global temperature to below 2 degrees celsius over pre-industrial levels, become more resilient to climate change, and directing money toward reducing greenhouse emissions. It spells out that different countries will take different roles in this agreement because each has different needs.

Article 3 says that each country will plan their own specific response to this agreement rather than the UN dictating what exactly they do.

Articles 4-5

Article 4 is pretty long, so it gets its own section; it’s long, however, because it’s the first bit that lays out what the signers are responsible for doing. Here’s what they have to do:

  • Reach peak greenhouse gasses as soon as possible, and reduce greenhouse emissions from there. It’s spelled out that this will take varying amounts of time for varying countries, but the aim is for the second half of this century (so 2050 and on)
  • Make a plan and communicate what it is
  • Make sure the plan is more aggressive than what they’re doing currently, rather than coasting on at the same rate
  • If they are a developed country, take the lead in this effort. If they are developing, just try their best.
  • Support developing countries’ efforts since they tend to be poor
  • The least developed countries and small islands get special consideration for their circumstances
  • Provide the information needed for clarity and transparency
  • Communicate on their progress every five years
  • Coordinate their time frames as well
  • Anyone at any time can decide to be more aggressive than their communicated plan
  • The secretariat will record everyone’s plans
  • Communicate the data needed to hold each country accountable with honesty, integrity, transparency, comparability (the same numbers reckoned according to the same method across the board), and consistency
  • Take into account existing methods and guidance from the committee
  • Take other countries into account when making their plans to minimize the impact for all
  • If they have agreed to act jointly, they need to tell the secretariat that
  • Be responsible for their own carbon emissions even when working in concert

Article five asks them to:

  • Preserve sinks of greenhouse gasses, such as forests
  • Continue upholding existing agreements, including reducing deforestation, conserving, and managing forests sustainably (aka replanting).

Article 6

Article six begins by specifying clearly that this is a voluntary agreement, and that therefore “cheating” (double-counting and so on) is going against the spirit of volunteering. Basically, it says nobody made you sign, so don’t go back on this agreement later or try to weasel out of it.

It then goes on to set up a meeting with the overall goal of reducing greenhouse gasses, which signatories to the agreement can attend on a voluntary basis. It also spells out that if someone counts an emission reduction which happened as a result of the meeting’s strategy as part of their contribution to the overall agreement, that exact reduction cannot be counted by another party. (For example, if the committee decides to spend a bunch of money to improve trains between Paris and Frankfurt, both France and Germany cannot claim that as part of their efforts; either can claim it, or neither, but not both). It spells out that money raised by the committee meetings outlined above should go toward paying administrative fees and helping developing nations meet their agreements. It spells out that rules and procedures will be decided by the committee.

Finally, article six mentions non-market, holistic approaches. This includes building capacity, adaptation, and finances. I’m not a hundred percent sure what approaches it’s talking about, but all this does is recognize that such approaches are important, and suggest that they be used.

Article 7

Article seven talks about resiliency and reducing vulnerability to climate change, so that the effects do not cause as much damage. The signing parties recognise that this is a valid and important concern, particularly for developing countries, since often it’s all they can do. Action taken to adapt should be driven by the individual countries, responsive to gender, and fully transparent, leaning on the best science we have as well as traditional and indigenous knowledge. The signing countries should strengthen their cooperation on this, including:

  • sharing information, lessons learned, and best practices
  • strengthening arrangements to share knowledge and provide technical support and guidance
  • improve climate science, early warning systems, and research so that better decisions can be made
  • helping developing countries make plans, identify needs, and prioritize
  • taking better and more durable actions

Non-country signers are urged to support countries in this. Each signer is asked to participate in planning and acting, including:

  • taking action
  • planning to take action
  • measuring climate change so they can take action
  • monitoring and measuring the effects of actions taken
  • building resilient economic and ecological systems, such as by managing natural resources in a sustainable way

(Real harsh terms, right? I hope you don’t think it’s me being vague: all of this is spelled out in vague, high-level terms like this)

Everyone who signs is supposed to come out with a personalized adaptation plan, making sure it doesn’t make life harder for developing countries. The plan shall be updated periodically, and recorded by the secretariat. International support shall be available for developing countries. Finally, the stocktake in Article 14 will recognize adaptation plans.

Articles 8-10

Article 8 spells out that preventing, minimizing, or handling damage due to climate change is also important. It upholds the existing Warsaw International Mechanism for Loss and Damage associated with Climate Change Impacts, and says that it can be enhanced or strengthened by the committee coming out of this agreement. It lays out some suggested areas for cooperation:

  • early warning systems
  • emergency preparation
  • slow onset events
  • events that involve permanent damage (I think we’re talking flood cleanup here)
  • risk assessment and management
  • risk insurance, risk pooling, and so on (like home insurance, but for countries)
  • non-economic losses
  • resilience of communities, livelihoods, and ecosystems

Article 9 asks developed countries (like the US) to offer money for developing countries (like India) to help them out with their plans. This needs to be scaled up from previous efforts, as they weren’t working fast enough. They have to report on this every two years in a transparent way, and the approval mechanism for developing countries to get the money should be simple and transparent. This is the Green Climate Fund, to which the US has pledged $3 billion; the goal was to get to $100 billion per year globally, and we’ve only paid $50 million of our pledge so far. You can see where the money comes from and goes to in their infographic portfolio website.

Article 10 talks about technology development and transfer, and urges parties to cooperate. It spells out that financial help may be available for this, and puts together a team to work on that aspect.

Articles 11-15

Article 11 talks about capacity building, particularly for island nations. This is talking about improving the ability of poorer, developing nations to actually implement these suggestions. It should, like everything else, be country-based, transparent, and routinely communicated on.

Article 12 basically just says that climate change education and access to information is important too.

Article 13 outlines a special concern for transparency. It sets up for a system to be put in place to ensure transparency without putting undue burden on the signers, and asks each signer to provide an inventory of emissions by source and removals by sink (forests remove carbon emissions) and the information needed to track their progress against their pledges. Developed countries are asked to provide information about how they’re contributing to help developing countries, and the latter are asked for information on how they’re receiving and spending the funds. All the information is subject to a technical expert review, akin to a peer review.

Article 14 establishes a “global stocktake” that will occur in 2023 and every five years after. It is meant to list out how everyone’s doing and whether we need to adjust course.

Article 15 establishes a committee to “promote compliance” in a way that is not adversarial, doesn’t punish anyone, and is transparent.

Articles 16-20

Article 16 basically says that the annual conference on climate change will serve as the meeting of the people who signed this agreement as well. Countries and organizations that signed other climate change agreements can watch, but cannot speak at this meeting. They’re allowed to set up sub-committees and so on to get things done. It was 2015 when this was held in Paris, so there’s only been one meeting since then.

Article 17 says that the secretariat of the Convention on Climate Change is the secretariat of this agreement as well, so there’s no need to appoint another one. Article 18 does the same for the sub-committee on scientific and technological advancement. Article 19 allows other sub-committees for the Convention to serve this agreement if the Convention wants them to.

Article 20 outlines when and how you’re allowed to sign the agreement, when and how you’re allowed to ask to sign it later, and who is bound when various special groups sign.

Articles 21-29

Article 21 explains when the treaty will take effect for each country. Article 22 explains that amendments are handled just like the previous Convention. Article 23 handles annexes by saying they’re just like the previous Convention. Article 24 covers disputes in the same way.

Article 25 explains that everyone who signs gets one vote, except that regional organizations get one vote for each of their members states. I believe this covers the EU.

Article 26 explains the Secretary-General is the one who receives signed copies, amendments, and withdrawals. Article 28 says you can withdraw from the agreement three years after it goes into force for you (so, for the US, 4 November 2019). The withdrawal cannot take place any sooner than one year later (so 4 November 2020). If you withdraw from the Convention on Climate Change, you also withdraw from the Paris Agreement. From reading that document, it has the exact same rules, meaning Trump can probably withdraw from the Paris Agreement in as little as a year by withdrawing from the Convention on Climate Change (which entered into force for the US back in 1994).

Article 29 says that the Secretary-General hangs onto the original agreement, in English, Spanish, Arabic, French, Chinese, and Russian.

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Happy Mother’s Day

Some mothers are awful.

I want you to remember that. Today, everyone’s going to be talking about mothers. Everyone’s going to talk about this special kind of love, this unconditional, selfless love that mothers have for their children. They’re going to talk about how mothers work tirelessly, never once complaining, to make sure you have what you need. How mothers are always there to lend a listening ear, how they’re always the first person you turn to when you need to feel better. There will be pictures of smiling, saintly-looking mothers embracing daughters and sons, captioned with the same old cliches.

But not all mothers are like that.

Some of you out there are waking from nightmares about your mother. Some of you are forcing a smile on your face as strangers and adverts urge you to call your mother, send her flowers and gifts, be grateful for her. Some of you are cancelling plans or dreading going out at all. Some of you are wondering if you’re the problem. If mothers are so amazing and so unconditionally accepting, why doesn’t yours accept you? Why doesn’t yours love you?

It’s not your fault. Some mothers are awful. Please remember that.

I’m going back to bed to see if the nightmares have stopped yet.

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What’s in House Bill 1628 (AHCA) Anyway?

Taking a breather from the ACA, which is existing law, let’s look at the first serious attempt to “repeal and replace” it: House Bill 1628. You can find the full text here if you want to read it yourself, which I always encourage; an informed populace makes democracy work, and it’s nowhere near as long as the Affordable Care Act.

Let’s get started!

Title I: Energy and Commerce.

Subtitle A is entitled Patient Access to Public Health Programs, and contains only three short sections.

The first section amends some of the funding in the ACA. The specific funds removed are earmarked to provide “expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs”; with this bill, that funding stops after 2018, instead of continuing on indefinitely. It’s a sliding scale up, so in 2018 it’ll be 900 million a year, but by 2025 and thereafter it’s 2 billion per year.

The second section amends the 2015 Medicare Access and CHIP Reauthorization, which is another reform besides the ACA. Wikipedia says this law changed how doctors were paid under Medicare, and extended the Children’s Health Insurance Program (CHIP). This section amends it to add an additional $422 million in funding for the year 2017. That’s right — this is spending more money. I’m surprised too.

The third section defunds Planned Parenthood. It claims that no money the federal government pays to states can be used for any organization that 1) is a non-profit (specifically, a 501(c)(3) nonprofit, which most nonprofits you donate money to are), 2) performs family planning services, 3) offers abortions, and 4) received $350 million from Medicaid in fiscal year 2014. Why that last bullet point? So that it only applies to Planned Parenthood and not to any nonprofit that offers abortions, is my guess. Ugh.

In short, when they say “patient access”, they mean “removing of”, not “adding to”.

Subtitle B is called Medicaid Program Enhancement. There are seven sections here. This is where the “repeal” starts.

Section one removes the bit from the ACA about letting hospitals sign people up for Medicaid without needing so much paperwork and time, as outlined here (I think). It goes on to end the part where you can make more money and still be on Medicaid, reducing it from 133% of the FPL back to 100%. It removes the funding for in-home assistants. It removes the “presumptive eligibility period” for pregnant women that states can opt-in to, where they treat you assuming you’ll be eligible and work out the finances later.

Section two repeals the medicaid expansion in the ACA. It reverts another few places where the eligibility cutoff is amended to 133% of the poverty line instead of 100%, some ending in 2017 and some in 2019 for some reason. It grandfathers in anyone who is enrolled on the last day of December 2019, so if this applies to you (and the bill passes with this language in place), stay enrolled and you will have some period of being grandfathered in. It also removes the requirement that state benefits cover “essential benefits” such as mental health (for the full list, see my series on the ACA).

Section three repeals cuts to the DSH program. I don’t pretend to understand all of this, but the gist of it seems to be that there’s a loophole where states can claim unlimited federal funds for certain hospitals, and the ACA asked the Secretary to reduce the federal funds spent in this manner. This bill cancels that order as of 2019, and provides any state who does not expand medicaid (aka red states) exemption from the order immediately.

Section four… I don’t have words. It specifically calls out lottery winnings as “income” for the basis of eligibility for medicaid. Note the grandfathered exemption above; if you get disenrolled via winning the lottery, you would not be able to re-enroll if you’re in that 100-133% of the FPL zone. At first glance, this seems entirely redundant; if you won more than $5k, the winnings already count as income. However, it turns out, Medicare is based on monthly income, not annual. Lottery winnings don’t count as income for that month, because it’d be a pain in the ass to disenroll someone for a month because they got lucky. This bill says if you won $80k, the winnings count for that month; more, and you add an extra month for every $10k extra you won. There’s a line about still being eligible if it would cause “undue hardship”, but I can’t imagine how it would play out in practice. Not to mention, there’s the part where you’d lose at least 40% of that to taxes — remember, this is adjusted gross income, not net.  The Guardian did a fact check and came up with under 400 people affected by this legislation in a given year; Fred Upton may insist this will save “hundreds of millions”, but I just don’t see it.

This section also repeals retroactive eligibility; under the ACA, you can file for medicaid up to three months after treatment and get coverage for that treatment, but under this bill it’d be the same month only, starting in October of this year. If you’re eligible and not already on medicaid, it’s a good idea to apply immediately. This section also removes the ability of states to determine how much home equity is needed to disallow you from medicaid, making them all use the same rule.

The next section allows states that did not expand Medicaid more federal funds to cover people who are not insured. This allots up to an extra $2B/yr in federal funds for the states to grab if they did not expand Medicaid. You can see which states these are here. Look how red they are.

The next section forces states to check if you’re still eligible at least every 6 months, and they get up to 5% more funds to pay for activities to check more often than that. This will, of course, lead to people being kicked off medicaid sooner when their income increases.

The last section (117) allows states to force medicaid recipients to work. That’s terrifying, because one reason a lot of people are on medicaid is inability to find work in the first place; remember that for most people, welfare and similar benefits are a temporary thing between jobs, while the GOP keeps characterizing your average welfare recipient as too lazy to work. There are exemptions for pregnant women (ending 60 days after the end of pregnancy), children under 19, people who are sole parents for children under 6 or disabled, and people who are under 20 and enrolled in university. The title of the section reads “Work Requirement Option For Nondisabled, Nonelderly, Nonpregnant Adults”, but there’s nothing in here about adults with disability or elderly adults. Sloppy editing? Was language like that in there, but removed later?

In short, when they say “program enhancement”, they mean “removing access to”.

Subtitle C is called Per Capita Allotment For Medical Assistance. It has one section, which is directly inserted into Title XIX of the Social Security Act. The main gist of this legislation is to get states to reduce how much they pay out for medical things. If they pay out more than their “target” amount, they receive less federal funds as a result. The target is set to “the amount paid out per-capita in 2016”. This is a major change to how Medicaid is funded, and it would seem like it’d encourage states to do whatever they can to remove “expensive” people from the insurance while striving to insure “cheap” people with no health problems to make up for it. The Kaiser foundation points out that seniors and disabled people are “expensive” in this system. Not to mention, costs have been running away in health care for years, so unless that’s curbed, Medicaid will pay for less and less every year.

Starting in 2020, states will be able to apply for a 10-year trial run of an alternate plan, called “block grant” funding. This means they’d get a set amount per year based on their target per-capita payment and the number of enrolled people they had the previous year, making for less bookkeeping. This means medicaid funding can run out, leaving states in the lurch, though they can apply any excess funds to the next year.

Subtitle D is called Patient Relief And Health Insurance Market Stability. It has 7 sections.

It starts out by repealing the bit of the ACA that makes plans cheaper for people under 400% of the federal poverty limit. Flat out repealing. Starting in 2020, you pay more.

Section two establishes the ‘Patient and State Stability Fund’. This fund can be used only for the following:

  • Helping people who are “high-risk individuals” and “do not have access to health insurance coverage offered through an employer” enroll in the health exchanges
  • Bribing companies to stabilize premiums. Well, they say “providing incentives”, but same diff.
  • Reducing the cost of insurance to people who use a lot of insurance and/or live in a rural area that’s not profitable to insure
  • Encouraging people to participate in the market
  • Increasing options in the market
  • Promoting preventative care
  • Paying for maternity coverage and newborn care
  • Inpatient or outpatient care for treatment of addiction and mental illness
  • Early identification of children and young adults with serious mental illness
  • Paying for health care services
  • Reducing out-of-pocket costs

States have to apply for this fund, but it’s automatic approval, and they are considered approved until 2026. If they do not submit a plan for using the funds (I think?), they must use it for paying insurance companies (the second bulleted item) 75% of any claim between $50k and $350k. This fund starts at $15 billion per year, but drops to $10 billion per year in 2020. In 2020, there’s an extra $15 billion that can only be used for maternity, newborn, addiction, and mental illness payments. The amount each state gets depends on how many claims they see and how many uninsured poor they have. The state also has to match funds, starting at 7% and ending up with 50% in 2026. If a state does not apply, the whole fund goes to insurance companies.

Section two also establishes a “Federal Invisible Risk Sharing Program”, which is another $15B to pay premiums for people. Eligibility requirements to be determined later. If this bill passes, a plan will have to be created within 60 days. I love that they don’t know how it’ll be used, but they know how much it’ll cost.

Section three establishes the Continuous Coverage Penalty. It forces insurers to charge 30% extra to people who did not buy insurance the previous year, starting in 2019. I can’t find any mechanism for the government to collect that money; they’re just telling the insurance companies how to do business. “Free market” capitalism?

Section four is entitled “Increasing coverage options”, but what it actually does is remove the requirement that all plans cover essential health benefits.

Section five amends a portion of the ACA called “Prohibiting Discriminatory Premium Rates”, which banned rates from varying more than 3:1 based on age. This allows you to charge up to five times as much based on age.

Section six allows states to apply to waive coverage of essential health benefits if they can show how it will reduce average premiums, increase enrollment, “stabilize the market”, stabilize premiums for people with pre-existing conditions, or increase the choice in plans. Obviously adding plans that cover nothing automatically increases choices, since there’s more plans. Furthermore, if those are plans that apply to people with pre-existing conditions, it increases their enrollment and stabilizes the premiums. Win-win! Nevermind the price-gouging, that’s built in.

(What part of this bill is promoting the general welfare again? It seems like it was written by insurance companies).

Section seven claims that no part of this Act can be used to justify discrimination in rates by gender, or limiting access to individuals with preexisting conditions. So that’s good news. They can charge you more, but they can’t not cover you.

Subtitle E just sets out $1B to cover the administrative costs incurred by the other sections.


Halfway there!

Subtitle A is called Repeal And Replace Of Health-Related Tax Policy. The first section removes the option for advance payments on the tax credit for helping people with their premiums starting in 2018.

Section two would apply to 2017, allowing it to help cover catastrophic plans, prohibiting it from paying for any plan that includes abortion services, and preventing it from applying to transitional plans. It also clarifies that you’re allowed to buy abortion coverage separately as long as no tax credit money goes toward it. It also clarifies that people are allowed to offer plans that cover abortion, and subsequent abortion side-effects are not considered abortions.

Section two also allows you to use non-exchange plans to qualify for the premium tax credit. See below.

Section three prevents small businesses from getting tax credits if they fund plans which cover abortion.

Section four removes the individual mandate penalty. Section five removes the employer mandate penalty. Section six repeals the tax on health plan benefits and premiums in employer-sponsored plans. Section seven repeals a tax on over-the-counter medication. Section eight reduces the tax on HSAs.

Section nine makes it possible to put unlimited money into an FSA. Section ten repeals another tax (on medical devices). Section eleven allows employers who are claiming a tax deduction to not have to reduce it by the amount of any federal subsidy they received for medicare — essentially a tax break for them.

The twelfth section decreases the percent of income you have to spend on medical expenses before deducting it from your taxes from 10% to 5.8%. The thirteenth repeals two more taxes (on income).

The last big change here is to tax credits. Under the ACA, you get a tax credit if you’re below the FPL to allow you to buy insurance. Under this bill, that’s replaced with an age-dependent credit instead of an income-dependent one. It ranges from $2,000 to $4,000, while the old credit depended on the price of a silver level plan. The Kaiser Foundation has put together an interactive map of how this would affect someone with a given age on a state-by-state basis. You’ll notice at the highest income level, everyone under 60 pays less; the poorer and older you are, the more you end up paying under the AHCA.

The limit on contributions to an HSA is raised to your deductible plus your out of pocket limit, which is nice. For a joint HSA, both spouses are allowed to make “catch-up contributions” ,which is also nice. You’re also allowed to start a HSA up to 60 days after enrolling in a high-deductible plan. That’s the end of Subtitle A.

Subtitles B, C, and E each repeal taxes: prescription medication, health insurance, tanning, and investment income. Subtitle D repeals a limitation on tax deductions for insurance companies for payment over $500,000 to an employee, officer, or director. Not sure what that loophole is, but it sounds like a closed loophole being re-opened.

And that’s the bill. It’s a “repeal and replace” that’s big on the repeal and distressingly light on the replace.

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What’s In the ACA Anyway? (Part 8)

Welcome back! As always, you can follow along at congress.gov, which offers a (very dry) summary and a (even drier) full text version.

Title V: Health Care Workforce

This title was written in the context of a pending nursing shortage projected to be something like a million openings by 2022. You can see at that second link that there’s also likely to be a shortage of physical therapists, dental hygienists, pharmacists, dietitians… basically anything that isn’t as glamorous and well-paid as a doctor but still requires specialized scientific knowledge.

Subtitle A: Purpose and Definitions

This section starts out by laying out the purpose of the title: to improve access to and the delivery of health care services for all individuals, particularly low income, underserved, uninsured, minority, health disparity, and rural populations. It plans to do this by improving both the quality and the quantity of medical professionals available, particularly in low-income areas.

Subtitle B: Innovations in the Health Care Workforce

This section lays out the National Health Care Workforce Commission, which apparently has never met since it was formed. This is apparently Congress’ fault: “Although members of the Workforce Commission were appointed September 30, 2010, Congress has been unable to appropriate the $3 million requested by the administration to fund the commission.” (source). Despite being well liked, this title’s funding never got approved due to the Republican congress You can read more about it at the New York Times.

This commission was meant to, among other things, hand out grants for states to do the following:

  • Analyze State labor market information in order to create health care career pathways for students and adults
  • Identify what jobs need such pathways
  • Improve the education system to produce more people who are qualified to go into health care training programs
  • Break down existing barriers preventing people from going into these fields

Each state getting a grant has to put forth matching funds: 25% of the total they’re asking for.

This section also lays out a provision for its own assessment of the health care workforce, to devise a plan to put together a response. You can find the research findings of this center online as well. A study was also conducted specifically for Alaska, the findings of which can be found in PDF format.

Subtitle C: Increasing the Supply of the Health Care Workforce

This is where the fixing the problem part begins.

First off, there are special student loans only available to people in med school; to qualify for one, previously you had to pledge to practice medicine until the entire loan was paid off, but this amends it to require 10 years of practice instead. The penalty for noncompliance was previously a 12% interest rate, but is amended to being 2% higher than compliance, due to changing interest rates across the student loan industry. This section also specifies that you don’t need a FAFSA to get one of these loans, as parent financial information is not relevant

The next section increases the amount of federal loans available for nursing students by just straight increasing all the caps in the previous legislation.

The next section establishes student loan payments by the Federal government for anyone who is willing to work as a pediatrician in an underserved area for 3 years. Which is pretty swell. The next section establishes a similar repayment program for people who are willing to work in federal, state, or tribal agencies that are underserved, regardless of speciality. The section after that extends student loan forgiveness to people in “allied health” situations, such as emergency rooms or outpatient clinics. All of this is eligible for the grants provided in subtitle B.

The next section offers grants for mid-career training, which is where health care professionals take classes after college in order to keep current on the best practices. We’re always learning new things about health care, so most providers end up needing to do these from time to time.

The next section offers grants for nurse-run clinics. These clinics see 2 million patients per year, and often act as primary care for people who are uninsured or on Medicaid.

Did you know we have a Public Health Service Commission Corps? Apparently their job is to provide medical care to indigenous folks, prevent the spread of major diseases, improve the nation’s mental health, ensure that drugs are safe and effective, ensure that cosmetics are harmless, and support biomedical, behavioral, and health services research. The ACA removes the cap on the number of officers that can be enlisted, and adds a Ready Reserve to this force for burst capability.

Subtitle D: Enhancing Health Care Workforce Education and Training 

This subtitle allows the Secretary to pay for any of the following:

  • planning, running, or participating in professional training, such as a residency or internship, in family medicine, general medicine, or pediatric care
  • med students, interns, residents, or physicians in the above fields who cannot afford tuition
  • training people to teach the above fields
  • training physicians in community-based settings
  • training physician-assistants
  • creating professional development training
  • creating joint degree programs
  • creating more medical degree programs
  • training dentists and dental professionals
  • awarding schools and medical facilities who are doing well at training medical professionals in specific areas, such as chronic illness or underprivileged populations
  • creating training programs, awards, and fellowships in geriatric care, including geriatric dentistry
  • recruiting students for mental health, behavioral health, and social work
  • doing research and demonstration projects around prevention, cultural competency, disabilities, and reducing health disparities
  • creating nurse retention programs to prevent nurses from leaving the field

One section establishes grants for schools who are in programs to provide training and residency situations for people interested in long-term care facilities such as nursing homes (again, remember that the baby boomers are getting old enough to start needing that kind of care).

A demonstration program is put together in this subtitle to show the usefulness of non-dentist dental professionals in serving rural or underserved areas. Generally, oral hygiene is very important in a population, because poor oral health can escalate into poor overall health, but people tend to look at it as “just teeth” and not worry as much about it.

Another portion of this subtitle creates a loan repayment program for nurses the same way there are some for medical students. This includes nurse-midwives, but only if they are accredited programs, much the same as medical schools must be.

Another portion straight out establishes advanced degree programs at various schools in the fields of public health, epidemiology, and emergency preparedness and response. Furthermore, a one-year program is established to train nurse practitioners to be primary care providers, since they already are.

Subtitle E: Supporting the Existing Health Care Workforce

The first section here increases federal funds for medical schools to improve the number of minorities going into health care; we also here get some scholarships being created. The second section makes physician assistant education programs eligible for loan repayments. I’m not really sure at this point how or why they’re organizing all this; I’d have put all the loan repayment stuff together, but what do I know.

There are new grants established for med schools to not only improve diversity of skin color and background, but also diversity of specialty: promoting interdisciplinary training that includes midwifery, psychology, dentistry, and other training.

A special grant is set up for people working in underserved communities who want further education, including telelearning, conferences, and distance learning opportunities.

Grants that existed to help with retention are expanded to include bridge programs and degree completion programs, for people who were almost done with their degree but had to drop out.

A program is set up to educate primary care providers. Primary care providers are, by definition, the first line of detection in just about any field; this program educates them in chronic disease management, mental health, substance abuse, and preventative medicine. Chronic pain is often treated only with opiates, leading to substance abuse problems, and mental health problems are suspected to be widely underdiagnosed.

Subtitle F: Strengthening Primary Care and Other Workforce Improvements

This opens with Medicare payments to primary care practitioners and general surgeons in underprivileged areas. It then goes on to redistribute how many residents each hospital can have subsidized by the government, and allows for residents in non-provider settings to count those hours toward their residency requirements.

The next section allows the Secretary to pay grants for demonstration programs that will provide low-income individuals with training in fields that are likely to see shortages in the near future. This both improves employment and reduces shortages, so it’s basically a win-win here.

More money is allocated for teaching health centers to create residencies. Time that people in the National Health Service Corps spend teaching counts toward their service requirements, to provide more teachers for these centers. Furthermore, money is set aside for clinical training for nurses at hospitals as well.

Subtitle G: Improving Access to Health Care Services

More money is set aside for health centers in underserved populations. In addition, the Secretary is asked to come up with a comprehensive criteria for what an underserved population is, and the same for a health shortage area.

The Wakefield Act is extended, which provides more funding for the Emergency Medical Services for Children, whose purpose is improving pediatric emergency care.

A grant is outlined for centers where people with co-morbid chronic illness and mental illness can be treated holistically.

A commission is put together to review key national metrics in health and make suggestions as to further improvements.

Finally, a grant is put together for health centers that treat a large number of underserved people.

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What’s In The ACA Anyway? (Part 7)

Welcome back! As always, you can follow along at congress.gov, which offers a (very dry) summary and a (even drier) full text version.

Title IV:  Prevention of Chronic Disease and Improving Public Health

One of the things that leads to a high cost of care is, put bluntly, people getting sick. Especially if they’re getting sick with preventable diseases; every person who refuses a vaccine and has to be treated for measles or whooping cough takes up resources that could be used to treat someone with a broken arm or pneumonia, leading to longer waiting lists, crowded hospitals, and so on. So it makes sense to include programs to try and improve the overall health of individuals when you’re talking about health care reform.

Subtitle A: Modernizing Disease Prevention and Public Health Systems

This subtitle created the “National Prevention, Health Promotion and Public Health Council”, and appointed the Surgeon General as its chairperson. Like everything else created by this act, they have a website, so its not hard to see what they’re working on: reducing the number of smokers, preventing drug abuse and excessive drinking, “healthy eating”, active living, “injury and violence-free” living, reproductive and sexual health, and mental well-being. I won’t talk here about my feelings on our country’s emphasis on dieting to control health, but most Americans would agree that these things are generally meant to improve the health of individuals, right?

This section also created an Advisory Group. I believe the difference is that the council is made of government employees, while the advisory group is collecting non-government-employees, to ensure that there’s input from experts in the field as well.

Along with the council and advisory group are the usual slew of reports, funding, and studies. This also instructs the CDC to be involved, particularly in creating a “national science-based media campaign on health promotion and disease prevention” and a website where people can put together a personalized health plan. I am not certain what this is; I’m seeing things like this website, but I’m also seeing mentions of helping providers produce personalized plans for their patients, so this might be aimed at them instead. It’s through the CDC, so maybe it’s just this portal? The text specifies that it should be “a source of the most up-to-date scientific evidence relating to disease prevention for use by individuals”, and that it should include “a component that enables
an individual to determine their disease risk (based on personal health and family history, BMI, and other relevant information) relating to the 5 leading diseases in the United States, and obtain personalized suggestions for preventing such diseases.” If you can find that, let me know in the comments!

Subtitle B: Increasing Access to Clinical Preventive Services

This section begins by providing funding for school-based health centers. You can find an overview of what these are, where they are, and who they serve in the census that comes out every few years.

The next section is concerned with dental disease: it asks the CDC to put together a campaign for oral health, including creating a program to provide dental sealants to schoolchildren, and public education on oral health. Oral health is also added to the Pregnancy Risk Assessment Monitoring System, the National Health and Nutrition Examination Survey, and the Medical Expenditure Panel Survey.

Fun fact: Did you know that gum disease is linked to heart disease and low birth weight? You know, the leading cause of death in the US and one of the biggest factors for infant mortality? So dental care is definitely not something to overlook.

The next bit establishes personal prevention plan coverage for Medicare. Basically,  for free, everyone with medicare gets to have a physical (or “annual wellness visit”) with their doctor, followed by a consult to establish a plan to get them healthier tailored to their lifestyle and needs; the ACA provides for tooling to help physicians accomplish this. This plan includes a list of risk factors, and a schedule for followups to make sure you’re on track.

It also eliminates copays under Medicare for items that are recommended by the US Preventative Services Task Force, and authorizes the Secretary to continue adding anything they recommend in the future to this list. Right now this is mostly screenings for common issues, like hepatitis and tuberculosis, plus counseling for things like tobacco use, and some supplements. Vaccines are also called out by the ACA as explicitly free. Finally, there’s the usual grants to states who manage to come up with innovative new ways to improve general public health.

Subtitle C: Creating Healthier Communities

This section starts out with a carrot: money for states and cities who come up with innovative evidence-based programs for

  • create healthier school environments (including reforming school food, adding more physical activity, promoting emotional wellness, and preventing chronic disease)
  • creating infrastructure to give more people healthy food and an active lifestyle
  • developing programs for all ages that increase nutrition, physical activity, and socal and emotional wellness
  • developing programs for all ages that reduce smoking and chronic disease
  • creating workplace wellness programs
  • highlighting “healthy” food options at restaurants
  • reducing racial and ethnic disparities in health
  • meeting health needs of special populations

It also specially calls out programs for seniors aged 55 to 65 for physician screenings and referrals, probably aiming to reduce the burden of seniors 65+ by helping them get healthier earlier. The secretary is similarly asked to investigate programs for Medicare recipients to help them develop healthier habits. Another pilot program is commissioned later for people who use “community health centers” to be given access to the same kind of information.

This section also calls for the creation of standards around medical equipment to ensure it’s disability-accessible. This includes examination tables, chairs, scales, x-ray machines, and so forth.

There’s also a section on vaccines for adults, authorizing the state to purchase and deliver vaccines. An older act authorizing the states to hand out free vaccines (for adults and kids) was extended, and a study is commissioned to ensure that adults 65 and older are getting the vaccines they need. We usually talk about vaccines as though that’s something that only affects children, but flu and HPV vaccines can be enormously helpful for adults.

Do you remember when fast food places started putting calorie counts on the menu? That’s the ACA too, trying to solve the “obesity epidemic”. Their hearts were in the right places, I guess.

This is also the place where nursing mothers get a boost: employers must offer a place for them to express breast milk that is not a restroom, and must allow time to do so for a year after a child is born. However, that is not required to be a paid break.

Subtitle D: Support for Prevention and Public Health Innovation

This is where the science really kicks in! We open with funding for research into public health services and symptoms. This research specifically includes

  • evidence-based practices aimed at preventing diseases
  • how well academic models translate to reality, and
  • effective strategies for delivering services in the real world

This comes in the form of an annual report.

Next, some changes to research standards. All reports or survey for the federal government must include the following:

  • data on race, ethnicity, sex, primary language, and disability status
  • data at the smallest practical geographical level (so that comparisons of regions can be made)
  • enough data to come up with “statistically reliable estimates” grouped by racial, ethnic, sex, primary language, and disability status

Each of the demographic categories listed above are held to certain standards, to prevent gaming the data by redefining groups. There are also standards to be developed in how the data is collected, and in the interoperability of systems so that the data can be shared. All of this is considered health data, and held to high privacy standards.

The Secretary is then asked to put together tools to help employers measure how well their employee wellness programs are going; this is explicitly forbidden from becoming a standard on how employee wellness programs must be carried out, but instead just a set of tools to help employers help themselves.

$190 million dollars is set aside for grants for studies into disease management and the prevention of epidemics.

As someone with a chronic pain condition, this is my favorite part: the ACA digs into pain specifically. It begins with the Conference on Pain, the findings of which were laid out in this document. Then, a committee is created to continue researching pain after the conference. Money is laid out for education in the area of pain management, including both acute and chronic pain. More and more we’re beginning to realize that chronic pain is very different than acute pain, and is a condition in its own right, requiring more nuanced treatment than an opiate prescription. Unfortunately, we have a lot of people hooked on opiates because we didn’t realize that sooner.

Finally, funds are laid out to tackle childhood obesity.

Subtitle E isn’t worth a heading; the senate concludes that the effects of wellness programs are hard to measure, and allocated some funds toward fixing that in the future.

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Let’s talk about gender

(I promise, I’m going to get back to the ACA bill real soon now. This is just some collected thoughts I’ve been meaning to write about)

Let’s start here: When I was little, I don’t think I was a little girl. My parents did, but I’m not so sure.

I didn’t want to join Girl Scouts, I wanted to join Boy Scouts. I played with Barbies, but they went on adventures to rescue Ken while riding on my stuffed animals (I used hairbands to attach them to the stuffed dogs). I played with army men and Legos and lincoln logs, making forts and staging large sieges. I created rules for how far you could move an army man in a turn using a ruler, so we could play out fair battles in the backyard. I wanted to be a dog. I rode bikes, and played pretend fantasies. I loved Pokemon. I wrestled, and I threw rocks, and I kicked and bit and fought dirty. I triumphed over my enemies, and I played with the boys more than I played with the girls. I wasn’t a tomboy; tomboys liked sports. But I didn’t really feel like a girl either.

I’ve described myself in the past as a failure of a girl. Literally, that’s been my gender: I’m a girl, but I suck at it so badly I barely qualify.

I’ve described myself as a nerd tomboy: like a tomboy, but with geekery instead of sports. And that mostly fits me. Most of the time.

Sometimes I see something depicting women or depicting men and I just don’t want to be a woman anymore. Sometimes I have dysphoria. Always, I really wish I had a penis. It just seems so much cleaner, so much less fussy, so much easier to deal with.

(To be fair: always I have some kind of dysphoria, but it changes from day to day)

Sometimes I put on my corset and I put on my dresses and I love how I look and feel. Sometimes I wear makeup. Mostly I can’t be bothered, but sometimes I do.

But sometimes I look at binders and long for something that would flatten my breasts so I can get the right silhouette.

I crossdress, daily, for work: I wear men’s clothing, despite presenting female. This started out of fear and incompetence: I didn’t and don’t know how to dress like a woman in 2017. I can dress like a woman in a time when gender roles were more rigid, but I can’t seem to get the hang of the fluidity in dress expression, where the rules are firm yet subtle, hard to tease out. Off the clock I wear jeans and t-shirts.

I want to be androgynous. But you can’t look androgynous and be fat. Everyone who you see androgynous is thin, so they don’t have much in the way of breasts, and keeps their hair short enough to be ambiguous. I would love to play with gender, but I feel trapped into a female expression.

I don’t know what words to use for myself other than queer. This is one of the things I was thinking about when I changed the name of my blog: my gender is “Other” and I’m not sure how to specify.

This hasn’t been an article so much as a word dump, a feelings vomit about gender. Is anyone out there who feels like me? Does anyone relate? Sometimes I feel alone. I don’t want to be.

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What does Alabama Senate Bill 20 say?

I got into a discussion today about Alabama Senate Bill 20, so I figured I’d do a piece on this bill in the same vein as the ACA ongoing series. The full text is available for this bill online as well.

This is a nice, short, concise bill. I’m skipping the synopsis because I don’t believe that part would be legally binding, and we’re keeping an eye out for loopholes here.

This bill amends the existing legislature Sections 22-9A-17, 30-1-5, 30-1-12, and 23 30-1-16 of the Code of Alabama 1975. It removes sections with the following effects:

  • The Office of Vital Statistics will record all marriages
  • A Probate Judge will prepare the form to give to the OVS
  • The officiant who performed the marriage will fill out and return the form to the judge within 30 days of the marriage ceremony
  • The judge must forward the completed marriage forms to the OVS on or before the 5th of each month
  • The entire current process for amending a marriage recorded in the above manner

If this bill becomes law, all of that ceases to exist. It is replaced with the following:

  • “the only requirement for a marriage in this state shall be for parties who are otherwise legally authorized to be married to enter into a marriage as provided herein.” This literally states that anyone who wants to be married can, provided they pass a few tests
    • The judge still gets to collect the same recording fee as before, though. This bill does not affect the civil costs of marriage
  • This bill creates a “marriage document” that contains the following:
    • Identifying information about both parties (as laid out elsewhere in existing legislature). I think this is a circular reference: it says 22-9A-6, but that just says that each document is spelled out below, and 22-9A-17 (the bit pertaining to marriages) is what’s being amended here.
    • The full legal names of both parties
    • A notarized affidavit (basically a legally binding statement) from both parties that states the following:
      • The person signing is not already married
      • The person signing is at least 18, or is at least 16 with parental consent
      • The person signing is legally competent (not under guardianship or something like that)
      • The parties are not related legally (with a reference to the laws that pertain)
      • The person signing is not being coerced
    • A signature from each party
  • A  marriage is valid as of the date it was “executed”, so long as the court is informed within 30 days. This appears to mean that signing the form makes you legally married.
  • A ceremony may be conducted. However, the state may not require that a ceremony be conducted.
  • The forms mentioned above are considered a “legal record of the marriage of both parties”
  • A copy of the form will be sent to the OVS
  • If there’s an error on the form, a corrected version may be filed, and the costs are the same as filing the original. The amended versions will say they have been amended, and the judge will file them and forward them to OVS. If the two parties disagree on what the amendment should be, they have to settle it in court.
  • This bill does not affect divorce, child custody, child support, or spousal support. (It says that right on page 10)
  • All requirements to obtain a marriage license are repealed
  • The requirement to hold a ceremony is repealed
  • The Alabama Law Institute will create a form to meet the needs above
  • This bill will take effect 30 days after it is signed

Other parts of the bill change parts of the existing legislature:

  • Parental consent for 16 year olds is still required, but the requirement changes to being an affidavit that is notarized and filed
  • Instead of keeping a record of marriage licenses issued, the judge now keeps a record of marriages recorded

And that’s it. That’s the bill.

Now for my editorializing: I think this is a good bill, on the face of it. The current concept of how marriage works is that the government checks if the marriage is legal, then issues a permission to get married (the “license”). Then, an officiant performs an actual ceremony; this officiant has to be registered with the courts, making the choices in many areas only consist of a clerk or a Christian pastor. Religious officiants often put extra requirements on the couple, like marriage counseling or religious tests; civil clerks require you to get married in a small ceremony at the courthouse, since they don’t usually travel. So it makes you conform to what is “normal” in your marriage ceremony. Furthermore, the law requires a ceremony; you can’t just decide to be married on your own, you have to have the big hoopla. Under this bill, you decide what you want the event of your marriage to look like, and then tell the court “by the way, we got married”. This is less burdensome to the couple, and allows for a wider variety of ceremonies — if you wanted to have a handfasting in your backyard, and you don’t have a Wiccan officiant, you would have to also go to the courthouse, and that courthouse visit is considered your “real” wedding since that’s the official date your marriage began. Under this bill, you just do it, and tell the court “we were married on X date”. It’s getting the government out of the business of legitimizing religious ceremonies, and I approve.

I hope that helps.

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