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Today is a preview of the future of the U.S. healthcare debate. After a month and a half of relative calm, there’s finally some excitement in the Washington health policy world. This morning, four Republican senators introduced a last-ditch effort to overhaul Obamacare while Sen. Bernie Sanders and fellow liberal Democrats are releasing an updated single-payer healthcare bill. Though the chances of either of these bills passing anytime soon are slim and none, respectively, they do provide us with a preview of the future of the U.S. healthcare debate. The bill released by Sens. Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada and Sen. Ron Johnson of Wisconsin, can be seen as the first major bill being unveiled by Republicans in a post-repeal universe. Though it would cut some spending, repeal some taxes, and give more flexibility to the states, it more or less keeps much of Obamacare intact. This is a far cry from Republicans’ long position of wanting to fully repeal and replace Obamacare, an effort that is unlikely to be revived as both chambers of Congress and the Trump administration look toward tax reform. Though the bill released by the four Republican senators itself may not become party orthodoxy, conceptually it could be where many other members of the party end up in a few years — in favor of making changes to how Obamacare functions rather than wiping it away. Meanwhile, Sanders is capitalizing on liberal grassroots momentum generated by his presidential campaign and the failure of Republicans repeal efforts to push his single-payer plan, picking up several Democratic endorsers, but also earning his share of skeptics among Democrats in red states, including Sens. Heidi Heitkamp of North Dakota and Joe Manchin of West Virginia. There are also those who are conflicted in between. This is the battle for the future of the Democratic Party — between those who believe that the United States should function more like a European welfare state and those who prefer more modest or incremental changes building on the current welfare state.

Welcome to Philip Klein’s Daily on Healthcare, compiled by Washington Examiner Managing Editor Philip Klein (@philipaklein), Senior Healthcare Writer Kimberly Leonard (@LeonardKL) and Healthcare Reporter Robert King (@rking_19).  Email for tips, suggestions, calendar items and anything else. If a friend sent this to you and you’d like to sign up, click here. If signing up doesn’t work, shoot us an email and we’ll add you to our list.

Here’s what’s in the Republican senators’ new Obamacare overhaul bill. Sens. Lindsey Graham of South Carolina, Bill Cassidy of Louisiana, Dean Heller of Nevada and Sen. Ron Johnson of Wisconsin unveiled their new Obamacare overhaul bill Wednesday morning. The legislation would replace the federal money currently being spent on the Medicaid expansion, Obamacare tax credits, cost-sharing reduction subsidies and the basic health plan dollars and turn them into block grants to states, which would have more flexibility to design their healthcare systems. Some of the options for which states could use the federal funding include through providing premium subsidies so people could buy private coverage, funding assistance for out-of-pocket costs for residents or creating high-risk programs or reinsurance pools. States would get similar funding whether they expanded Medicaid under Obamacare or not. The legislation would repeal the individual and employer mandates and the medical device tax. It would keep in place the requirement for insurers to cover people with pre-existing illnesses, but allow states to more easily waive Obamacare regulations. Here is the text of the bill.

Conservatives skeptical. Some Senate conservatives are pretty skeptical of the overhaul bill. Sen. Rand Paul, R-Ky., told Politico that the bill leaves in too much of Obamacare’s taxes and regulations. Sen. Ted Cruz, R-Texas, was a bit more conciliatory in talking with reporters about it on Tuesday. "I think Graham-Cassidy has some positive aspects to it and it could well be part of how we come together to honor our commitment to repeal Obamacare,” he said. “The devil is always in the details.” Cruz speculated that Obamacare repeal has about 45 or 46 votes in the Senate. “We need 50. And I think it’s entirely possible that Graham-Cassidy could be part of how we get there,” he said.


Time is not on Republicans’ side … again. Republicans have until the end of the month to pass the bill or else the instructions to use budget reconciliation expire. Reconciliation lets a bill be passed in the Senate with only 51 votes, but the instructions on how to use reconciliation for passing Obamacare repeal expire Sept. 30. Republicans aren’t shying away from the difficulty of another last-minute push for repeal. Cassidy recently told reporters he hopes to get a score from the nonpartisan Congressional Budget Office in about two weeks and would hope to get a vote in the last week of the month. If the Senate passes Graham-Cassidy before September ends, the House can pass it whenever it wants. The only catch is that the House cannot make any amendments to the bill. If it does, that means that it would go back to the Senate, which wouldn’t be able to use reconciliation to pass the bill again since the instructions would have expired.


For John Thune, a successful vote on Graham-Cassidy a ‘double-double bank shot’ The third-ranking GOP senator made the sports reference in response to whether the partial repeal bill can be passed in the Senate. “If we can get some scores it would take an extraordinary lift to get that done before the deadline,” the South Dakota Republican said Tuesday. “I know there is a lot of interest in our conference.”


‘Carnac says 6’ We asked Rep. Mark Meadows, R-N.C., about the chances on a scale of 1 to 10 that Graham-Cassidy makes it to the House. “On a scale of 1 to 10? I would say it’s a 6,” he said late Tuesday. “Carnac says 6,” he added in a reference to the psychic character created by Johnny Carson. Meadows said he hasn’t read the bill yet, which is expected to be released today.

Cassidy: Bill not meant to be partisan. Cassidy said he has reached out to 10 Democratic senators for their support on the bill. But the legislation doesn't have any Democratic co-sponsors. "We're not trying to be partisan," the Louisiana Republican said during a Wednesday hearing of the Senate Health, Education, Labor, and Pensions Committee. "We are actually trying to be bipartisan by allowing a blue state and a deep red state come up with a solution that works best for their folks."

Republicans ponder what to do next if the bill fails. Since the latest repeal effort is in a precarious state, what happens with Obamacare after September? The answer is the GOP doesn’t know. A new reconciliation vehicle would have to be created for Republicans to pass any Obamacare repeal legislation with only 51 votes.That reconciliation vehicle would have to pass the House first, since reconciliation bills originate in the House. So wary Republican House members would have to take another difficult vote for legislation that may not get through the Senate. Thune told reporters that Obamacare repeal likely would be punted “into a time when we have another reconciliation vehicle available for it. The question of whether or not you can do both tax reform and healthcare reform on one reconciliation vehicle … those are questions we are asking,” he said.

What’s in the ‘Medicare for All’ bill? The bill is set to be introduced this afternoon by Sen. Bernie Sanders. The Vermont independent is introducing the legislation, which would expand the Medicare program to all Americans. The bill would pay for emergency surgery, prescription drugs, mental healthcare and eye care without a co-pay. Plus, people who are 18 and younger would receive a "universal Medicare card" when the law goes into effect, while others who are not on Medicare would be phased into the program after four years, according to the Washington Post, which received the bill early. People who now receive private medical coverage under a job would lose that plan to receive Medicare instead, and their employers would pay higher taxes rather than pay for the cost of private plans. Private health insurance companies would be used to pay for elective treatments, such as plastic surgery. According to Vox, the Department of Veterans Affairs plans and the Indian Health Services plans would continue to exist. But the bill does not spell out how large the tax increase would be to pay for these services.

Sanders’ campaign plan had $32 trillion pricetag. An analysis of a similar plan Sanders introduced when he was running for the Democratic nomination for president, from the left-leaning Urban Institute, projected that such a system would increase federal spending by $32 trillion over a decade. With more costs shifting to the federal government, the analysis projected that the private sector would spend $22 trillion less than it otherwise would have and states would spend $4 trillion less.

Sanders: ‘Healthcare is a right.’ He predicted that health insurers, drug companies and Wall Street will oppose his "Medicare for All" bill, but he said it's time to treat healthcare as a right, not a privilege. "Now is the time for Congress to stand with the American people and take on the special interests that dominate healthcare in the United States," he wrote in a New York Times op-ed. "Now is the time to extend Medicare to everyone. Needless to say, there will be huge opposition to this legislation from the powerful special interests that profit from the current wasteful system. The insurance companies, the drug companies and Wall Street will undoubtedly devote a lot of money to lobbying, campaign contributions and television ads to defeat this proposal," he wrote. "But they are on the wrong side of history. Guaranteeing healthcare as a right is important to the American people not just from a moral and financial perspective; it also happens to be what the majority of the American people want," he added. A recent poll showed 60 percent of those polled want everyone to have Medicare access, he said.

Democrats divided ahead of single-payer release. Senate Democrats are set to announce a new push for single-payer healthcare around 1 p.m., featuring several 2020 hopefuls touting Sanders’ legislation. But divisions remain in the Democratic caucus over whether government-run healthcare may be going too far. Some of the most vulnerable Senate Democrats running for re-election in 2018 are not offering a warm embrace of the policy. Instead, some Democratic senators are angling to expand Medicare to people ages 55 and up, from the current 65 years old. The rift reveals divisions in the Democratic Party on what their next step will be after Obamacare. Democratic Sens. Cory Booker of New Jersey, Kamala Harris of California, Elizabeth Warren of Massachusetts and Kirsten Gillibrand of New York, all of whom have been suggested as 2020 presidential hopefuls, are among the co-sponsors of the Sanders bill. But other Democrats were reticent to support single payer, especially those up for re-election in 2018 in states that President Trump won handily. "I've been very focused on making sure the Affordable Care Act works for the people of my state," said Sen. Heidi Heitkamp, D-N.D., who is running for re-election in a state Trump carried by 36 percentage points.

Democratic House leaders are not on board. House Minority Whip Steny Hoyer of Maryland said Tuesday that Medicare-for-all would have "significant administrative and other issues." He said the House Democratic leadership is focused more on preserving Obamacare. House Minority Leader Nancy Pelosi also said that the most immediate goal is protecting Obamacare, declining to endorse the bill. Hoyer said he isn't concerned a Democratic push for a Medicare-for-all system could turn off centrist votes in the midterms as Democrats look to flip districts that could allow them to retake the House next November. "There has always been, and there still are, people in the Democratic Party who ... would like to see a public option,” Hoyer said.

Insurers slam single-payer proposal  "Whether it's called single-payer or 'Medicare For All,' government-controlled healthcare cannot work," David Merritt, executive vice president at AHIP, said in a statement. "It will eliminate choice, undermine quality, put a chill on medical innovation, and place an even heavier burden on hardworking taxpayers. We should build on private-sector successes, not abandon them." AHIP encouraged politicians to instead partner with the healthcare industry to come up with solutions, and said the problem with the system rested with the high cost of providing healthcare. Merritt noted government was partnering with private insurance companies to offer coverage, both through Medicare Advantage at the federal level, which covers a third of people on Medicare, and Medicaid managed care, which is through 39 state governments and partially paid for by the federal government. "The most effective way to ensure affordable care and coverage is to strengthen the private market's ability to serve the American people, whether it's building upon private plans serving nearly 180 million people who get their coverage through their employer or the tens of millions who depend on private plans that partner with public programs," he said.

Hillary Clinton: ‘It’s going to be challenging’ to get universal healthcare because of cost. If the proposal were to include the prospect of increasing taxes, Democrats would have a challenging road ahead, Clinton said in an interview with Vox in which she was asked about the single-payer bill. She raised the single payer plan Sanders endorsed during the campaign, and noted he had introduced the bill several times as senator. “When somebody finally read it he couldn’t explain it and couldn’t really tell people how much it was going to cost,” she said. Though she acknowledged that she didn’t know the particulars of the latest version bill, as it had not been introduced when she was interviewed, she raised the possibility of arriving at universal coverage through a gradual transition, such as expanding Medicare, Medicaid or allowing the government to set the price of prescription drugs. “I think we should be focused politically, realistically and aspirationally on continuing the expansion of Medicaid and going to those states that have not yet expanded it and making the political case every day for as long as it takes,” she said. She noted she was in favor of a public option and a Medicare buy-in where the age of eligibility would gradually be lowered.

House to vote on slew of health-related amendments as part of minibus spending bill. The votes are scheduled for this afternoon, and among them are amendments that would increase programs for opioid addiction treatment and for mental illness. Other amendments involve increasing funding for research on Alzheimer's disease, pediatric cancer, lyme disease research, and research on water to test for harmful toxins.

Hatch, Wyden reach deal to extend child insurance program. Senators from both parties reached a deal to extend the Children's Health Insurance Program by five years and transition to a lower funding level. Sens. Ron Wyden, D-Ore., and Orrin Hatch, R-Utah, announced the deal late Tuesday. The program expires at the end of the month, and legislative language is expected to be released in the coming days, according to the Senate Finance Committee, of which Hatch is chairman and Wyden is the ranking member. The bill aims to eventually lower the funding for CHIP to a "traditional federal-state partnership and provide additional flexibility for states." Obamacare added a 23 percent funding hike to the program when the healthcare law was approved in 2009. It is not clear what the funding level would be reduced to or when the update would go into effect. CHIP provides block grants to states to provide health insurance for low-income children. The program, which was created by Hatch and the late Sen. Ted Kennedy, D-Mass., traditionally generates bipartisan support. It was last reauthorized in 2015.

House Democrats demand Trump administration fund Obamacare navigators. The administration announced in late August that it was cutting the grants to the groups, known as navigators, nearly 40 percent, or about $23 million. It then froze the funding on Sept. 1 that was expected to be awarded the following day. Democrats have accused the Trump administration of deliberately trying to sabotage the law through these kinds of moves so that fewer people will enroll in the program, making it less successful. "Navigators are an essential resource for the American people, and the navigator program is critical to the success of open enrollment," wrote 31 Democrats in a letter to top federal health officials, led by Rep. Carol Shea-Porter of New Hampshire. "We urge you to unfreeze these funds immediately. ... Destabilizing the navigator program could further compound the challenges consumers will face in understanding when and how to enroll." The navigator groups expect to hear this week about whether they will receive any funding and how much. According to the administration, members of the navigator program in 2016 received $62.5 million in federal grants to sign up just 81,426 people, which is about 0.7 percent of total enrollees.

McCain will work in Washington during cancer treatment. Senate Armed Services Committee Chairman John McCain will not return home to Arizona for his extended brain cancer treatment, and will instead undergo radiation and chemotherapy near Washington, D.C., "while maintaining a regular work schedule" in Congress. McCain spokeswoman Julie Tarallo announced the decision Tuesday as McCain oversaw the Senate's debate and consideration of the fiscal 2018 defense authorization bill, which sets spending levels for the Pentagon and other national security accounts. McCain will receive targeted radiation and chemotherapy treatments at the National Institutes of Health in Bethesda, Md. McCain had planned to receive treatment at the Mayo Clinic in Phoenix.

Obama's former CDC chief launches global health initiative. Dr. Tom Frieden, former President Barack Obama's director of the Centers for Disease Control and Prevention, will preside over a global health initiative that will include efforts to lower sodium and ban trans fat from food as a way to reduce deaths from cardiovascular disease. The initiative, called Resolve, is backed by $225 million in funding from the Chan Zuckerberg Initiative, the Bill & Melinda Gates Foundation and Bloomberg Philanthropies, and will be partnering with the CDC, the World Health Organization and the World Bank. The organization's goal is to save 100 million lives by going after certain ingredients in foods that contribute to heart disease, responsible for third of deaths worldwide. The second part of its mission is to help low- and middle-income countries prepare for pandemics through training and supporting epidemiologists and setting up teams that will investigate and stop outbreaks.

Shkreli apologizes for promising a reward for Hillary Clinton's hair. Martin Shkreli, former Turing Pharmaceuticals CEO and convicted felon, apologized Monday for posting he would "pay $5,000 per hair" from Hillary Clinton during her book tour of What Happened. "I want to personally apologize to this court and my lawyers for the aggravation that my recent postings have caused," Shkreli wrote in a letter to the judge overseeing his case, filed with the court Monday. "I understand now, that some may have read my comments about Mrs. Clinton as threatening, when that was never my intention when making those comments. I used poor judgment but never intended to cause alarm or promote any act of violence whatsoever," he added. In response to his initial post, a court motion filed in New York Thursday revealed that federal prosecutors called on a judge to remove Shkreli's $5 million bond and place him behind bars for dangerous public conduct. Prosecutors said the incident demonstrated Shkreli was unable to meet his post-trial burden and that he does pose danger to the community. Shkreli later posted on Facebook that he was joking and responded to the prosecutors' request by saying "F--- the government!" Shkreli was convicted in August on several counts of securities fraud for lying to investors about his failing hedge fund. He also was convicted on one count of conspiracy to commit securities fraud.


Axios The effect of the Medicaid expansion on the uninsured

The Hill Bernie Sanders flexes power on single payer

Roll Call Opioid epidemic continues to ravage the midwest

Politico GOP split over fixing or gutting Obamacare as deadline looms

Associated Press Carbon monoxide and nursing home deaths reported after Irma

New York Times Five dead after Florida nursing home goes without air conditioning

Washington Post Single-payer pushes healthcare debate decidedly leftward

STAT News The race for a Zika vaccine slows, a setback for efforts to head off future outbreaks



WEDNESDAY | Sept. 13

Sept. 13. Hogan Lovells. 555 13th St. NW. Food is Medicine Coalition National Symposium.

Sept. 13. Marriott Wardman Park. 2660 Woodley Road NW. 2017 Association for Accessible Medicines Biosimilars Council Conference. Includes keynote by CMS Administrator Seema Verma. Agenda.

Noon. 485 Russell. American Association for Cancer Research to host a congressional briefing to announce the “AACR Cancer Progress Report 2017.”

1 p.m. G50 Dirksen. Congressional briefing hosted by the American Psychiatric Association on “Telemedicine in America: Increasing Patient Access to Care & the Physician Perspective.”

1 p.m. National Press Club. 529 14th St. NW. Covered California to release a report on the importance of marketing and outreach for the Obamacare exchanges.

2 p.m. President Trump to participate in bipartisan meeting.

THURSDAY | Sept. 14

10 a.m. 430 Dirksen. Senate Health, Education, Labor and Pensions Committee hearing on stabilizing the Obamacare exchanges, with testimony from healthcare stakeholders. Details.

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.

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

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