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5 key questions for the House-Senate tax negotiations. House and Senate Republicans seeking to reconcile the differences between their tax bills this week will face the harsh reality that not all of the tax breaks in the two bills can be signed into law and that the GOP will have to choose which ones live and which ones die. Congressional Republicans and President Trump have momentum on taxes, following the Senate’s passage of the Tax Cuts and Jobs Act in the early hours of Saturday morning. But they will quickly run into two constraints as they move to conference on the two bills. The first is that they are limited to only a $1.5 trillion net tax cut over 10 years, thanks to instructions written into the budget process underlying the tax legislation. Because not all the tax cuts in both bills overlap with each other, not all of them will fit into that $1.5 trillion maximum. The second is the Senate rule requiring that the bill not add to federal deficits beyond the 10th year. With those parameters, Republicans face several key decisions, one of the most significant of which is whether to include a plan to repeal Obamacare’s individual mandate penalties in the final bill.  

House Republican: Dems need to make more concessions on Obamacare. A top House Republican said Democrats will need to make concessions that make them “wince” to get a vote on two Obamacare stabilization bills. The comments from Rep. Tom Cole, R-Okla., Monday come after the two bills looked headed for passage in the Senate after a deal to win support from Sen. Susan Collins, R-Maine, on the tax legislation. But while President Trump and Senate GOP leadership gave support for the bills, such a commitment in the House has been lacking. Cole, a member of the House’s whip team, said the two bills are going to be a tough sell to Republicans as they're currently written. “If that is what you want to get through, you had better put something with it that Republicans like because in the package right now there isn’t anything commensurate with what they are being asked to give up,” he told reporters Monday. The commitment from the Senate GOP and Trump to support the two bills was crucial in getting Collins to vote for tax reform early Saturday. Collins has said the two bills can help blunt the impact of repealing Obamacare’s individual mandate that everyone get insurance. But Cole said he didn’t believe that getting mandate repeal was a concession for Democrats. “We are gonna get that regardless if they want it or not,” he said. “If we get it then it will be on the tax bill and none of them are helping us with the tax bill.”

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But Collins thinks that Trump’s support is enough to get bills through the House. The Maine Republican said she received an “ironclad commitment” from Senate Majority Leader Mitch McConnell, R-Ky., and Trump that the two bills would become law by the end of the year. Missing from that statement is a commitment from House Speaker Paul Ryan. “You don’t think that the president has influence with people on the House?” Collins responded to a question Monday about whether Ryan supports the bill. One bill from Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would reimburse Obamacare insurer payments for two years and in return give states more flexibility to waive insurer regulations. A second bill from Collins and Sen. Bill Nelson, D-Fla., would give states $10 billion over two years to set up a reinsurance program to help cover the sickest claims from Obamacare insurers, thus lowering premiums for everyone else. Ryan initially opposed Alexander-Murray when it was released this fall, as did Trump.

Republican leaders reject Freedom Caucus, rally support for two-week spending bill. House Republican leaders on Tuesday told rank-and-file lawmakers they should support a short-term spending bill that will keep the government fully functioning until Dec. 22, rejecting a push by a faction of House conservatives to pass federal funding legislation that would last until at least Dec. 30. House Rules Committee Chairman Pete Sessions, R-Texas, said his panel plans to mark up the rule for debating a two-week spending bill lasting until Dec. 22, not Dec. 30. On Monday, about two dozen conservatives held up an important tax reform vote in protest over the spending bill language. They demanded a promise that the legislation would not expire on Dec. 22, a date they said would give Democrats leverage because of the desire among lawmakers to give into their demands to escape the Capitol before Christmas. But Republican leaders appear to be rejecting the demand, despite the possibility that conservatives could block the legislation.

Poll finds Democrats and Republicans rank healthcare as top priority, but for different reasons. A new poll finds Republicans and Democrats still cite healthcare as their top priority, but the focus of that priority is very different. The poll from Politico and the Harvard T.H. Chan School of Public Health released Tuesday found Republicans want Congress to take another stab at repealing Obamacare. However, Democrats want Congress to fund the Children’s Health Insurance Program. Republicans put Obamacare repeal on top of a list of 15 priorities, with 40 percent calling it an “extremely important priority,” according to a report from Politico. Another 33 percent found fixing the current problems in Obamacare was a major concern. But for Democrats, the biggest priority is refunding the Children’s Health Insurance Program with 48 percent. Reauthorizing CHIP nearly beat out stricter gun laws at 47 percent as a priority and giving more money for hurricane relief to Puerto Rico at 43 percent. Lowering high drug prices came in with 35 percent, Politico said. The poll was conducted from Nov. 15-19 among 1,009 adults. It does not list a margin of error.

Pro-Obamacare group targets New York lawmakers over tax reform. An Obamacare advocacy group is targeting two New York Republican lawmakers in an effort to get them to vote against any tax reform bill that includes a repeal of the law’s individual mandate penalty. The radio ads by the group Save My Care try to strike at a divide among Republicans that opposed the Obamacare repeal in May but backed tax reform in November. The House version of the tax bill does not include repeal of the individual mandate penalty, but it was added to the Senate version that passed early Saturday morning. The lawmakers targeted by the ads are New York Reps. John Katko and Claudia Tenney. Katko voted against Obamacare repeal in May but voted for tax reform, while Tenney voted for both bills.

Community health centers languish without federal funding. Community health centers that provide medical care to low-income people are laying off staff and reducing hours to grapple with Congress’ inability to provide new federal funding for them. The last time community health centers were funded was in 2015 as part of a larger set of health legislation that also extended the Children’s Health Insurance Program. But like CHIP, community health center funding expired Sept. 30. A potential funding vehicle could be an end-of-the-year omnibus spending bill or a short-term continuing resolution, but those packages are in flux.

Short-term funding bill includes help for children’s health insurance program. A two-week spending bill to fund the government would provide help for several states low on money for the Children’s Health Insurance Program. The joint resolution released Monday would fund the government until Dec. 22. It also would allow for emergency funding to states until the end of the year as Congress has yet to fully fund the program. While most states won’t run out of CHIP funding until early next year, a few states are in danger of running out of money this month. The Trump administration has been giving those states redistribution funding, which is CHIP funding that wasn’t spent in prior years. CHIP provides block grants to states to fund health insurance for low-income children. The new legislation, expected to be voted on this week, details how a state can receive redistribution funding and how much a state should get.

Government-funded healthcare accounted for most revenue for the five largest insurers.

Medicaid and Medicare accounted for 59 percent of revenue for UnitedHealthcare, Anthem, Aetna, Cigna and Humana in 2016 — a doubling since 2010, according to a Commonwealth Fund study published in the journal Health Affairs. The combined total has grown from $92.5 billion in 2010 to $213.1 billion in 2016. Authors of the study note that these insurers pulled out of the Obamacare exchanges while they profited in other government-funded healthcare. They recommended that policymakers consider requiring exchange participation to receive contracts from Medicare and Medicaid, as is required in New York and Nevada.  “Many states’ ACA marketplaces are facing uncertainty about insurer participation and have fewer choices for consumers, as some insurers have left the markets,” said Cathy Schoen, lead author of the study and a senior scholar at the New York Academy of Medicine. “At the same time, some of these companies have thrived from growth in public coverage in those same states. Requiring insurers that participate in Medicaid and Medicare to offer marketplace coverage could help shore up those state markets.”

Trump administration expects several states to set Medicaid work requirements. The head of the Centers for Medicare and Medicaid Services said Monday that she expects several states to implement plans that would require people who receive healthcare coverage through Medicaid to have to work. "Once the first waivers are approved then we will see many [states] coming into line," CMS Administrator Seema Verma said, answering questions from reporters at an event held in Atlanta by the Centers for Disease Control and Prevention. Under the proposal, Medicaid enrollees would be required to take classes, volunteer or work for at least 20 hours a week. The requirements generally contain exemptions for people who are disabled or pregnant and for children and older adults. The requirement would help enrollees move out of poverty, Verma said Monday. The proposal is part of state efforts to shed Medicaid rolls. It also is a target for Republicans who say that the Medicaid program should go toward paying for care of the most vulnerable Americans, such as people who are disabled, rather than able-bodied adults.

Verma: Medicaid waivers under Obama a 'hill to climb' for states trying to tackle opioid crisis. Verma said that states under the Trump administration will more swiftly be able to enact programs to help address opioid addiction than they were able to under the Obama administration. Verma on Monday said the administration was working to approve waivers specifically under the Medicaid program, which covers low-income people in many states. She touted efforts in Utah and New Jersey that aim to provide more treatment to people with addictions from opioids such as heroin and prescription painkillers. "The former administration set it up where they had a lot of upfront requirements for states," Verma said about the waiver process under former President Barack Obama. "They made the states run through a bunch of hurdles," she continued, calling the process a "hill to climb." (View full briefing.)

Elizabeth Warren questions Kellyanne Conway's qualifications to lead opioid battle. Sen. Elizabeth Warren, D-Mass., is questioning the ability of White House adviser Kellyanne Conway to coordinate the Trump administration's efforts to fight the opioid crisis. In a Monday letter to White House chief of staff John Kelly, Warren suggested the Conway isn't ready to lead that effort. "This crisis requires swift, decisive action from the Trump administration to support addiction patients, their families, and their communities that are struggling to find long-term solutions," Warren wrote. "While the White House has made numerous announcements about the opioid crisis ... these steps are not adequate without critical funding and strong, experienced leadership." She asked a series of questions, including what experience Conway has leading these sorts of initiatives. "Has Conway led or coordinated any interagency efforts to address the opioid epidemic?" she asked. "Does Ms. Conway have any previous experience working in public health, or working with drug or addiction policy?" Warren added. "Does she have any experience managing a public health agency or organization in government or the private sector?"  

Amount of fentanyl seized at border last year was 742 times the 2013 rate. The amount of fentanyl seized by U.S. border agents has soared in recent years, from two pounds in fiscal year 2013 to about 1,485 pounds from Oct. 1, 2016, to Sept. 30, 2017, according to federal data published Tuesday. Customs and Border Protection reported finding 2.14 million pounds of drugs, including 5,760 pounds of heroin. The majority of illicit drug smuggling took place on the Southwest border between the U.S. and Mexico. CBP officials said they are seeing a growing number of synthetic, or designer, drugs being smuggled into the country through international mail and express consignment carriers.

Hawaii prepares to deliver New Year's present to caregivers. After 21 years of trying to pass long-term care legislation, Hawaii this summer became the first state to pass a bill that gives funding to caregivers who assist family members who have become disabled as they age or have cognitive challenges as their brains succumb to dementia or Alzheimer's disease. Hawaii this summer passed the Kupuna Caregivers Act, which aims to ease the financial burdens for caregivers of older adults by offering up to $70 a day to help pay for services such as adult day care, home-delivered meals, and transportation. To qualify, a caregiver must work at least 30 hours a week. About $600,000 in state funding was set aside for the program, and the governor's office estimates that the state has more than 154,000 unpaid caregivers. Though the law took effect in July, payments haven't gone out because the state's Office on Aging is working with the attorney general to work out some of the details. Proponents hope the program will be operating by January.

RUNDOWN

The Hill
Five questions for the CVS-Aetna deal

STAT News Pregnant women who need medications face a risky guessing game. A federal task force is trying to help.

Washington Post Here’s why it has been easier for Republicans to pass a tax bill than a healthcare one

Wall Street Journal After push on taxes, Republicans line up welfare revamp next

Bloomberg Senate bill doesn’t have House’s tax break for ‘unborn children’

Kaiser Health News ‘I’ve never been this busy:’ As Marketplace deadline nears, navigators feel the pinch

New York Times Why Trump is right and wrong on Obamacare premiums

Axios Obamacare mandate repeal may be less popular than the GOP thinks



Calendar

TUESDAY | Dec. 5

12:30 p.m. President Trump to have lunch with Senate Republicans at the White House.

Deadline for public comments on the Trump administration’s birth control rule, which contains religious and moral exemptions.

WEDNESDAY | Dec. 6

10 a.m. 2175 Rayburn. House Health, Employment, Labor, and Pensions Subcommittee hearing on "Workplace Leave Policies: Opportunities and Challenges for Employers and Working Families.” Details.

10 a.m. National Press Club. 529 14th St. NW. California Attorney General Xavier Becerra will discuss the legal actions his state has taken against the Trump administration. Details.

THURSDAY | Dec. 7

10 a.m. 430 Dirksen. Senate Health, Education, Labor and Pensions Committee hearing on the 21st Century Cures Act. Details.

Noon. Capitol Visitor Center. Congressional Meeting Room, South. Capitol Visitor Center. American Psychiatric Association briefing on “Improving the Physical Health of Patients with Serious Mental Illness:Identifying Breakthroughs in Approaches to Treatment.” RSVP to kdougherty@psych.org.

FRIDAY | Dec. 8

Deadline for Congress to pass a spending bill before the government runs out of money.

Noon. G-50 Dirksen. Alliance for Health Policy event on “The Role of the Health Care Workforce in Delivery System Reform.” Details.

TUESDAY | Dec. 12

8:30 a.m. AARP Family Caregiving Summit. Details.

10 a.m. 430 Dirksen. Health, Education, Labor and Pensions Committee hearing on prescription drug costs. Details.

10 a.m. Dirksen 226. Senate Judiciary hearing on “Oversight of the Ensuring Patient Access and Effective Drug Enforcement Act.” Details.

WEDNESDAY | Dec. 13

10 a.m. 430 Dirksen. Health, Education, Labor and Pensions Committee hearing on the 21st Century Cures Act focusing on mental health needs. Details.