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Trump tweet throws bipartisan deal into disarray. President Trump tweeted this morning that he couldn’t support a “bailout” of insurance companies that made a “fortune” on Obamacare. The 9:41 a.m. tweet was sent about an hour after Trump talked with Sen. Lamar Alexander, chairman of the Senate Health, Education, Labor and Pensions Committee and the agreement’s Republican architect. After the call, the Tennessee senator said at an event that Trump was encouraged by the deal but was still reviewing it. That review apparently didn’t take too long. The tweet throws into disarray a bipartisan deal announced Tuesday that would fund insurer payments that Trump cut off in exchange for reforms to Obamacare. Without Trump’s support, it appears unlikely the bill could advance out of Congress as some Republicans in the House are already skeptical of what they also call a “bailout” for Obamacare. A little more than two hours after Trump’s tweet, a spokesman for House Speaker Paul Ryan said he opposed it. Alexander said he hopes the deal is passed by the end of the year, but this morning’s comments from Trump and Ryan throw the deal, announced less than 24 hours ago, into serious doubt. Trump has had a series of mixed messages on this issue, as he has encouraged Alexander to reach a deal with Sen. Patty Murray, D-Wash., after he cut off the payments last week. Now it remains unclear whether the deal will move forward at all, with Trump giving skeptical Republicans cover to oppose a deal they were already wary of.

Alexander pledges to work with Trump to make deal stronger. Alexander tweeted Wednesday that he agrees with Trump that the money should go to consumers and not to insurance companies. He says the deal has strong language to prevent it from becoming a bailout. However, Alexander also said that he will work with Trump to make that part of the deal even stronger. It remains unclear what he means, such as if he is hinting at resuming talks with Murray.

Schumer: Trump doesn’t know what he is talking about. Senate Minority Leader Chuck Schumer bashed Trump during his opening remarks on the Senate floor. “The president doesn’t know what he is talking about in the compromise,” he said. “It doesn’t bail out insurance companies, it helps people who are sick and need healthcare.” Schumer said that Trump has been all over the place on a score of issues, including immigration and now on an Obamacare deal. He ended by hoping that Trump rethinks his position.

So what is in the deal? Murray and Alexander announced the broad outline for their Obamacare stabilization bill.

  • The deal would spend about $25 billion to $30 billion to fund Obamacare's cost-sharing reduction payments from now through 2019, pushing the issue beyond the next election.  
  • It would allow insurers to sell "copper plans" to people who are older than 30, which tend to have higher deductibles and lower premiums, making it possible that they would attract individuals who have fewer medical needs.
  • States would receive grants for outreach of $106 million for 2018 and 2019, paid for by existing user fees, to help people enroll in Obamacare plans.
  • States would be able to apply for waivers faster and the timeline would be shortened for them to be approved by federal officials, a process that currently takes months. The timeline under the new proposal would be cut in half, to 90 days, and could be fast-tracked in emergency situations. Also, states would only have to provide certification that they have a plan, rather than pass a full law before the waivers could be improved.
  • There would be some wiggle room in the requirements for waivers. The current requirement that out-of-pocket costs are “at least as affordable” as Obamacare would be changed to a more flexible “comparable affordability” standard. However, insurance offered under any waiver still has to be as comprehensive as Obamacare and cover at least as many people.

In a document Republicans circulated about the plan, they wrote that without insurer funds and state flexibility, the U.S. was headed down a “four-lane highway to single-payer solution.” "This is a small step, I'd like to undersell it, not oversell it," Alexander said, adding that he hoped to release legislation later this week. The Tennessee Republican cautioned that the changes wouldn't affect requirements that insurance plans cover people with pre-existing illnesses and would still cover essential health benefits such as mental health and maternity care.

However, conservatives were immediately skeptical of the idea of funneling money into what they see as a bailout to Obamacare insurers, without making sufficient gains in terms of giving states real flexibility. The remaining limitations placed on the waivers would make it difficult for conservative states to truly test free market plans, because all plans would still be subject to Obamacare’s requirements.

For anything to pass both the Senate and the typically more conservative House, it would likely have to do so along the same lines as spending agreements have in recent years -- with Democratic votes making up for large defections among Republicans. But at a time when Republicans are facing the threat of primary challenges in 2018, passing this bill is likely to only make matters worse. Having failed to deliver on their seven-year promise to repeal and replace Obamacare, they’d effectively be rescuing Obamacare from possible collapse, without much to show for it.

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.

Major GOP House group blasted the Obamacare deal as a 'bailout.’ The leader of the 170-member Republican Study Committee blasted the bipartisan deal as a “bailout.” The remarks from Rep. Mark Walker, R-N.C., head of the committee, underscores the difficulty of passing a narrow deal in the House. "The GOP should focus on repealing & replacing Obamacare, not trying to save it," Walker tweeted from the RSC's account. "This bailout is unacceptable." Many House Republicans have derided the payments as a bailout for the insurance industry, complicating efforts to pass any deal in the chamber.

Alexander responds that conservative victories require results. He pushed back on the GOP criticism of the deal, noting that he included real reforms to Obamacare that haven’t been made in years. “A conservative victory requires a result,” he said at Axios. “It has been eight years now, we have had 50 votes to repeal Obamacare and we lost them all.” Alexander then talked about parts of the deal such as expanding catastrophic plans and streamlining state waiver approvals. He said those are measures that are more “results than conservatives have achieved in eight years despite all the votes and all the speeches.”

Mark Meadows: Senate Obamacare deal is a 'good start.' Rep. Mark Meadows called the bipartisan deal to fund Obamacare payments a "good start" but shied away from full support. The North Carolina Republican told the Washington Examiner that the contours of the deal has promise, but more changes will be needed to lure support from conservatives. Meadows is head of the conservative House Freedom Caucus but was not speaking for the group, which has not taken a position on the deal that has yet to be released. Meadows was pleased the deal would allow for greater use of cheaper catastrophic plans and "greater flexibility to bypass Obamacare regulations." But he cautioned that more needs to be done. "It is a good start but must be augmented with real flexibility and additional consumer choices in order to gain conservative support," he said in a statement.

Where it stands with Democrats. Murray is trying to line up enough co-sponsors on the Democratic side. She told reporters that more details were being ironed out, but that she was optimistic they would be able to make an announcement soon. Schumer said the bill received "broad support" during a lunch with Democrats. "We think it's a good solution," he said. "I think there is growing consensus that in the short term we need stability in the markets." The bill, he added, would include "significant anti-sabotage provisions." But Democrats are not prepared to let Trump off the hook about the payments. In a letter sent to the White House by leaders in the House and Senate, they asked Trump justify his decision through providing documentation about analyses that had been conducted leading up to it. "The Affordable Care Act requires, and it is your obligation under the law, to make these payments," the Democrats wrote, siding with the Obama administration’s defense for authorizing the payments though they had not been appropriated by Congress. "Your repeated public statements about the ACA make clear that your decision to terminate these subsidies was motivated by a desire to sabotage the law. In fact, hours after announcing your decision, you invoked payment of CSRs as a negotiating tool, tweeting, ‘Dems should call me to fix!'"

Other key questions about the legislation's path to passage.

  • Will states benefit? States vary in terms of what deals they struck with health insurance companies. Some allowed insurers to file two separate rates, one that assumed that the cost-sharing payments would be made and one that assumed they would not. In North Dakota, for instance, insurers asked whether they could file new rates, but after they were told no, the insurer decided to remain in the market. If the funds are appropriated by Congress, some states would see a slight decrease in health insurance rates for silver-tiered plans. Some states, however, are still expecting large increases. In Maryland, for example, rates are expected to increase by an average of 33 percent, and in Virginia, by 43 percent, according to independent analyst Charles Gaba, who supports Obamacare. On the waiver side of the agreement, the question will be whether the waivers currently under consideration, such as one for Iowa, will be ready in time for open enrollment.
  • Will the Trump administration delay open enrollment? Open enrollment has been cut in half this year and will run from Nov. 1 to Dec. 15, for coverage that will begin on Jan. 1. Many of the changes being discussed in the proposal have little time to go into effect since lawmakers have to drum up support for the bill and then work on passing it. The deal under negotiation includes $106 million for states to use to help enroll people in coverage, but there might not be enough time for the legislation's elements, such as the new copper plan, to become available for 2018. A senior administration official told the Washington Examiner that no discussions have been held about delaying open enrollment.

Other bills introduced aimed at Obamacare. Democratic Sens. Michael Bennet of Colorado and Tim Kaine of Virginia on Tuesday introduced a bill to add a “public option” proposal to Obamacare that would allow a government-run plan to be sold alongside private plans. Meanwhile, Republican Sens. Pat Toomey of Pennsylvania and Tom Cotton of Arkansas introduced legislation to exempt people who earn less than the national median income from the individual mandate, which requires people to obtain health insurance or pay a fine. It also would exempt people whose premiums have risen more than 10 percent year over year, or those who live in counties that have only one insurer.

Ending Obamacare payments to lead to $1 billion in insurer losses this year. Obamacare plans will post losses of up to $1 billion for the rest of 2017 due to Trump's decision to cut off insurer payments, according to an analysis from the consulting firm Avalere Health. The funding losses vary from state to state, with North Dakota plans losing the least with $1.2 million for the rest of 2017 and Florida losing the most with $200 million. Health plans are required until the end of the year to sell more generous plans without federal help to cover the enhanced benefits, said Chris Sloane, senior manager at Avalere. That will cause the losses. Avalere looked at the average CSR payment in each state using federal data and compared that to the number of people who paid Obamacare premiums as of June.

PhRMA supports repealing drug bill. A news investigation from the Washington Post and CBS’s “60 Minutes” about an opioid-related bill sponsored by Sen. Orrin Hatch, R-Utah, and Rep. Tom Marino, R-Pa., has created much backlash from Democratic lawmakers, even though all of them voted for its passage just over a year ago. The report charged the bill with being responsible for neutering the Drug Enforcement Agency’s ability to going after drug companies that sell opioids, suggesting it did so with aggressive lobbying from the pharmaceutical companies. But on Tuesday the  Pharmaceutical Research and Manufacturers of America said it had never advocated for the passage of the bill, and its president and CEO, Stephen Ubl, called for its repeal. “We need to ensure the Drug Enforcement Administration has sufficient controls and authorities in place to prevent illicit diversion of controlled substances,” Ubl said in a statement. “We also urge Congress to consider whether existing criminal and civil penalties are sufficient for repeated failures of DEA registrants to ensure that they report suspicious orders for controlled substances in a timely manner.”


Kaiser Health News Chasing millions in Medicaid dollars, hospitals buy up nursing homes

Wall Street Journal Health insurers step up enrollment push as window to sign up shrinks

NPR Drug companies make eyedrops too big, and you pay for the waste

San Diego Union Tribune Death toll rises to 19 from Hepatitis A outbreak

Roll Call Poll: Most Americans disapprove of Trump’s subsidy slash

Bloomberg Does Trump support the Senate’s Obamacare deal? It’s hard to say.



Senate in session. House not in session this week.

1:30 p.m. 1615 H St. NW. U.S. Chamber of Commerce on “A Path Forward on Health Reform: Advancing Priorities and Innovative Solutions Amid Uncertainty.” Details.

6:30 p.m. 950 New Hampshire Ave. NW. Milken Institute School of Public Health. Panel discussion on “Female Genital Mutilation/Cutting: Half a Million Girls & Women in the United States at Risk.” Details.

THURSDAY | Oct. 19

10 a.m. 430 Dirksen. Health, Education, Labor and Pensions Committee hearing on “Examining How Healthy Choices Can Improve Health Outcomes and Reduce Costs.” Details.

TUESDAY | Oct. 24

1:30 p.m. Alliance for Health Policy webinar previewing open enrollment. Details.


10 a.m. 2358-C Rayburn. House Appropriations Committee hearing on “Down Syndrome: Update on the State of the Science and Potential for Discoveries Across Other Major Diseases.” Details.

8:30 a.m. 1777 F St NW. The Hill event with Dr. Ben Carson, secretary of Housing and Urban Development, on “The Future of Housing.” Details.