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Bernie Sanders’ single-payer bill filled with unanswered questions. Sen. Bernie Sanders, I-Vt., on Wednesday declared he was gearing up for a fight against pharmaceutical and health insurance companies as he works to gain support for his single-payer healthcare bill, and brushed off the Republican opposition to his proposal that quickly emerged. He said the GOP had “no credibility on the issue of healthcare.” Sanders released his bill with a growing sense of momentum for single-payer and the backing of 17 Democratic senators. But the bill came with a long list of unanswered questions. Most notably, the bill did not include any details about how the legislation would be paid for, even though a similar version of the bill he released during the presidential campaign was estimated to result in a staggering $32 trillion increase in federal spending over the next decade, according to the liberal Urban Institute. Cost has been the major stumbling block in efforts to enact single-payer at the state level, including in California and Sanders’ home state of Vermont.

The bill calls for building a single-payer system through Medicare, a program that is already facing financial problems. Yet Sanders wants to make the program more generous by adding benefits and stripping out co-payments and premiums that are helping to keep the current more scaled-down version afloat. Then, over a four-year period, he wants to offer Medicare to every American. Sanders has not said how the bill would be financed, beyond releasing a paper offering several possibilities, including dramatic tax increases on middle-class households, employers and the financial industry. Even if all of those theoretical options were adopted, resulting in a record-smashing tax increase of more than $16 trillion, it may not even get him halfway to paying for his program, if prior estimates are roughly accurate. During a press conference Wednesday, he said the plan was for him and other Democratic senators to travel the country to take input from the public and from hospitals. Though Sanders promises savings, citing lower administrative costs and the lower share of their economies that other nations spend on healthcare, his plan doesn’t lay out what type of payment rates to medical providers would be required to achieve such savings or address how it would handle a shortage of healthcare providers that would inevitably result from a drastic cut in payments.

It also wasn’t clear how the plan would fund care for people who are in the country illegally, payments that currently come in the form of charity care for hospitals. The proposal is also likely to raise questions about social issues policymakers have been debating at the state and federal levels. It includes funding for abortions, but it will open conversations about payments for gender reassignment procedures, assisted reproductive technology – for same-sex couples or heterosexual couples with infertility – and the possibility of government funds paying for people who are terminally ill to end their lives with medication, which is legal in some states.

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McConnell: Left wants government takeover. In response to Sanders’ proposal, Senate Majority Leader Mitch McConnell, R-Ky., tweeted that, "The Left is demanding an actual government takeover of healthcare," and shared a link to a list of stories that stated the single-payer proposal was a "litmus test" for Democrats. Sen. John Barrasso, R-Wyo., chairman of the Republican Policy Committee, said outside the Senate floor, "While Bernie Sanders' slogan may be popular, it's really the nuts and bolts and details that matter the most, and that's in terms of money, in terms of time and in terms of their freedom of choice when it comes to healthcare."

What does PhRMA have to say about Sanders’ attacks on its industry? The Pharmaceutical Research and Manufacturers of America initially shied away from responding to the single-payer proposal, saying it wanted to work with lawmakers on solutions, but the group issued a more direct statement when pressed on Sanders’ accusation that the industry is ripping off Americans. “Improving affordable access to medicines is the top priority for the biopharmaceutical industry,” spokeswoman Holly Campbell said. “Even though prescription medicine cost growth is slowing, it doesn’t feel that way for patients. Insurers are increasingly using benefit designs, which result in patients paying the full list price of a medicine, even if their insurer receives a significant discount. But more government bureaucracy is not the solution. Government mandated prices can create significant barriers to access, and instead we need common-sense reforms that promote innovation, enhance competition in the market and lower costs for patients.”

Healthcare spending is highest on doctors and hospitals. The industries have not spoken out about their position on Sanders’ proposal. But the plan would affect the sectors, which would not only face a higher influx of patients under a single-payer system, but likely also would see reductions in their bottom lines, given that Medicare reimbursements are less than private insurance. That would spell trouble for the industry in the form of lower salaries for doctors, laid-off staff and hospital shutdowns.

Single-payer bill would gut Hyde Amendment. Sen. Richard Blumenthal said Wednesday that the bill would gut a federal law that prohibits public funding from going toward most abortions. "Women have been denied their healthcare needs for too long," the Connecticut Democrat said at a press conference introducing the bill. "Consider the Hyde Amendment history when we pass Medicare for All." The Hyde Amendment does not allow federal taxpayer dollars to pay for abortions, but makes exemptions in the cases of rape, incest or a pregnant woman's health, though some states cover abortions through their Medicaid programs. Planned Parenthood praised the inclusion of abortion coverage in the bill.

Meanwhile, Republican senators look to overhaul Obamacare. A small group of Republican senators released a bill that wants to heavily reduce the federal government’s role in healthcare. Sens. Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada and Ron Johnson of Wisconsin put out the bill that they deemed is the “last shot” at repealing Obamacare. The bill would provide $1.2 trillion in Obamacare funding for Medicaid expansion and tax credits to states in the form of block grants from 2021 to 2026. The irony that the bill was being rolled out the same day as Sanders’ single-payer bill was not lost on Graham. He called single payer "Berniecare," and added that it would make the U.S. like Greece, which has had to make severe austerity cuts as part of a massive financial crisis. "What Bernie is doing is a great disservice to our country," Graham said.

What’s in the bill? It would run the block grants through the Children’s Health Insurance Program and subject them to a mandatory appropriation. It also would replace dollars spent on the Medicaid expansion, tax credits, cost-sharing reduction subsidies and dollars from the basic health plan for federal subsidies for states to create new coverage programs. The goal is to eventually give every state the same amount of money for each beneficiary who earns between 50 to 138 percent above the federal poverty level. The senators hope to give parity between states that expanded Medicaid and those that did not. However, initially some Medicaid expansion states will receive less money than they would under Obamacare. Under the bill the Medicaid expansion would be eliminated in 2019, but the senators say states can continue it if they wish under the block grant. However, since the bill runs the block grants through CHIP, the funding would need to be reauthorized since CHIP has funding only until 2026. Critics have said that could lead to the funding being eliminated.

Cornyn ready to work on overhaul bill. Sen. John Cornyn, R-Texas, told reporters Thursday that he is ready to work with the senators to see where the chamber is on the bill. “We are going to be trying to work with [Graham] and Sen. Cassidy to see where members are,” he said. The comments come a day after Graham criticized GOP leadership for not taking a larger role in lobbying support of the bill. “The idea that we can do this by ourselves is unreasonable," Graham said. He also prodded GOP leadership. "Everybody is telling us get us 50 votes and we'll help you," he said. "Here is my challenge to the Republican leadership: Act like this matters because it does. I am not ready to move on. I don't want this bill to die because we are just tired of dealing with healthcare." Cornyn said it has been hard to see where members are since there wasn’t a bill text before yesterday. He added there is still a lot of uncertainty since the Congressional Budget Office hasn’t scored how the bill would affect the deficit or insurance coverage. “We don’t have a score so we can’t vote on it without a score, but that’s been requested,” he said. “There is still quite a bit of interest but it is uncertain.”

Trump lends his support, but not endorsement. President Trump gave a statement praising the bill but stopped short of a full-throated endorsement of it. "Inaction is not an option, and I sincerely hope that Senators Graham and Cassidy have found a way to address the Obamacare crisis," the statement said. "Obamacare has been a complete nightmare for the many Americans who have been devastated by its skyrocketing healthcare premiums and deductibles and canceled or shrinking plans."

Cassidy takes Trump statement in stride. Cassidy wasn’t too concerned about the statement as he left the Senate late Wednesday. He told the Washington Examiner that Trump’s statement was “comme si, comme sa,” which is French for “so-so.” He expected, however, that Trump would help lobby support for the package.

Sen. Lamar Alexander says everyone needs to compromise on Obamacare. The chairman of the Senate Health, Education, Labor and Pensions Committee said Thursday that he believed appropriating cost-sharing reduction funds to insurers to help mitigate the cost of gross premiums in Obamacare was a reasonable tradeoff for a bill that would give states flexibility.  "To get a result, Republicans will have to agree to do something, additional funding through the Affordable Care Act, that some are reluctant to support. And Democrats will have to agree to something, more flexibility for states, that some may be reluctant to support," Alexander, R-Tenn., said during his opening statements at a HELP committee meeting to discuss the Obamacare exchanges. "That's what's called a compromise.” Republicans would like to see states have more leverage over the type of coverage they require insurers to offer, and they would like the waiver process under Obamacare, which allows states to change portions of the law, to move faster than it currently does. Democrats have said they are concerned that would chip away at Obamacare's protections for people with pre-existing conditions and are concerned that plans will not cover a range of medical care, including maternity care and mental healthcare.

Obamacare costs more in counties that don’t have as many insurers selling plans. That’s according to research from Avalere Health, which found that on average, counties with only one participating insurer this year have 9.6 percent higher premiums than those counties with two participating insurers, and 15.3 percent higher premiums than those counties with three or more participating insurers. For silver plans, average monthly premiums in counties where there is one insurer average $611 in 2017, compared to $557 per month in counties with two insurers and $529 per month in counties with three or more insurers. The situation is fluid as insurers haven’t signed contracts with states yet, but data from the Centers for Medicare and Medicaid Services show that 2.6 million people will have one health insurer offering Obamacare plans this open enrollment. “While many factors contribute to premiums — including local medical costs, health needs of enrollees and market uncertainty — lower competition in 2018 may contribute to higher premiums in some parts of the country,” said Caroline Pearson, senior vice president at Avalere.

‘Pharma Bro’ goes to jail. Controversial former pharmaceutical CEO Martin Shkreli was taken into custody Wednesday evening after a judge revoked his bail for offering a bounty for strands of Hillary Clinton’s hair. Shkreli, a convicted felon awaiting sentencing for securities fraud, said in a recent Facebook post that he would "pay $5,000 per hair" from Clinton during her book tour of What Happened. He later deleted the post, but federal prosecutors filed a court motion in New York requesting a judge to remove Shkreli's $5 million bond and put him behind bars for dangerous public conduct, saying he posed a danger to the community. In response, Shkreli posted on Facebook that he had been joking and addressed the prosecutors' request to put him in jail by saying "F--- the government!" He then later issued an apology for that statement, too. Shkreli gained infamy when he was the CEO of Turing Pharmaceuticals when he raised the price of an antimalarial drug by 5,000 percent from $13.50 per pill to $750.


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Roll Call Bernie Sanders, the man with single-payer clout

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THURSDAY | Sept. 14

1:30 p.m. Alliance for Health Policy Webinar on “New Administration, New Approach to Medicaid Waivers?” Details.

FRIDAY | Sept. 15

Sept. 15-19. Chicago. American Academy of Pediatrics conference. Schedule.

8 a.m. Newseum. 555 Pennsylvania Ave. NW. Atlantic forum on “Children and Cancer.” Details.

Noon. 325 Russell. Alliance for Health Policy event on “Chronic Pain & Opioid Addiction: The Role of Integrated Care.” Details.

MONDAY | Sept. 18

8:30 a.m. 1717 K St NW. Personalized Medicine Policy Forum. Details.

3 p.m. 1301 K Street NW. Washington Post event on Chasing Cancer; includes FDA Commissioner Scott Gottlieb. Details.

TUESDAY | Sept. 19

8:15 a.m. Ronald Reagan Building. 1300 Pennsylvania Ave. NW. Bloomberg Live event on “The Future of Healthcare: Unlocking and Supporting Value.” Details.

Noon. Harvard T. Chan School of Public Health event on “In Pursuit of a Single Payer Plan: Lessons Learned” with Vermont Gov. Peter Shumlin. Live Stream.

3 p.m. 430 Dirksen. PCORI event on “Addressing America’s Opioid Problem: The Need for Evidence-Based Strategies” with Sen. Shelley Moore Capito, R-W.Va. Details.

WEDNESDAY | Sept. 20

9 a.m. 562 Dirksen. Senate Special Committee on Aging hearing on “Disaster Preparedness and Response: The Special Needs of Older Americans.” Details.  

9 a.m. National Press Club. 529 14th St. NW. Researchers to announce global study from

Journal of Adolescent Health on “Common Cause of Multiple Social Maladies.”