Daily on Healthcare: Graham-Cassidy on brink of failure…preliminary CBO estimate expected today

New version of Graham-Cassidy announced as bill is on brink of failure. Senate Republicans released the latest version of an Obamacare overhaul bill Monday as they face a five-day window for passage and dwindling support within their own party. Three GOP senators came out against the earlier version of the bill bill, including Rand Paul of Kentucky, John McCain of Arizona and Ted Cruz of Texas. Sen. Susan Collins, R-Maine, has not explicitly said she would vote against the bill, but she has been conveying that she is leaning against it and that it would be difficult for her to envision a scenario in which it would earn her support. Though Cruz implied that his ally, Sen. Mike Lee, also may be opposed, a Lee spokesman said his position has not changed. Lee remains “very encouraged” by the bill being pushed by four senators led by Sen. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, but is seeking technical changes. As of Monday morning, Lee’s office said he was still analyzing the new version. The bottom line is: Republicans do not have the votes, and it’s difficult to see a path to getting there.

The latest version of the bill projects increased federal funding to key states Arizona, Kentucky and Alaska, which would have seen reductions under the previous version. Disagreements within the Republican Party have been similar to past versions of bills that would have repealed parts of Obamacare. Conservatives such as Paul and Cruz believe the bill doesn’t go far enough in repealing Obamacare and reducing the cost of health insurance, while centrists such as Collins believe the solution to the healthcare system should be established through bipartisan debate. And the timeline to win over McCain, who cast the deciding vote against the “skinny repeal” bill in July, has run short. McCain has called for “regular order,” which he defines as multiple hearings followed by open debate and amendments from both sides. The sole hearing scheduled on Graham-Cassidy is Monday afternoon in the Senate Finance Committee and involves testimony from federal and state health officials. Senate Majority Leader Mitch McConnell hasn’t changed his statement saying he intends to bring a bill to the floor for a vote this week, but the vote has not been scheduled. Further complicating GOP efforts is that Sept. 30 is also the deadline for re-authorization of the Children’s Health Insurance Program, or CHIP, which must occur every five years. Also this week: The deadline for insurers to sign contracts in most states is Sept. 27.

CBO score expected today. The CBO said that its analysts are aiming to release an initial estimate of the budgetary effects of the Graham-Cassidy bill at some point Monday. The estimate is expected to affirm that the bill would meet the deficit reduction requirements for passage through reconciliation, but to offer scant additional details about its broader effects on premiums and coverage.

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 [email protected] 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.

Paul not budging. The new changes weren’t enough to get the Kentucky senator on board. A spokesman for Paul’s office confirmed Monday he is still a “no” after reviewing the latest version of the Graham-Cassidy bill. Paul has been a vocal opponent of the legislation, which senators say is their last chance to repeal Obamacare, because it leaves in far too much of the law’s taxes. Paul has been angry that the bill leaves in 90 percent of the law’s taxes to fund the $1.2 trillion in block grants from 2020 to 2026. He said on NBC’s “Meet the Press Sunday” that he would vote for it only if the block grants were severely reduced. “If Obamacare were truly repealed, this entire trillion dollars would not be spent,” according to statement from Paul’s office outlining his demands. “This is the primary obstacle to my support, and only a significant reassessment of this trillion-dollar spending regime would get my support.”

If bill doesn’t pass, Graham vows to continue the fight. Graham, who is on the Senate Budget Committee, said he would press for passing another resolution on the budget that includes healthcare, saying he “will not vote for a budget resolution that doesn’t allow the healthcare debate to continue.” That would allow for a second pass at reconciliation in 2018, a midterm election year. Republicans had planned to use the resolution to pass a tax reform bill. Trump appeared to echo similar sentiments in comments about healthcare to reporters on Sunday, saying: “Eventually we’ll win, whether it’s now or later.”

How Obama knee-capped his own health reform. Experts and insurers say that while Republicans aren’t blameless when it comes to the strength or fragility of Obamacare, many of its wounds were inflicted by the Obama administration through executive decisions, waivers and deadline extensions. As a result, insurers incurred losses, which resulted in slashed choices for customers and hiked prices, especially for unsubsidized customers. Obamacare gives the secretary of Health and Human Services latitude to decide questions about open enrollment, customer outreach, and special enrollment periods. During the early years of implementation, leaving a wide array of issues up to a government healthcare agency meant experts could weigh in and provided flexibility and adjustment to the law. It also made the law vulnerable, however. The way the law was written, and the executive actions heaped on top of that fragile structure, have made it easier to dismantle now that former President Barack Obama is gone. The details of the law can change easily and significantly based on which political party is running the administration. Now additional problems have been raised under Trump, who does not want Obamacare to succeed but, rather, wants it to “implode” or be replaced. Read the Washington Examiner’s magazine feature.

Healthcare.gov expects multiple shutdowns during Obamacare open enrollment. The federal Obamacare exchange is expected to be taken offline for as many as 12 hours during all but one Sunday over the open enrollment period. The Department of Health and Human Services is planning website outages from midnight to noon every Sunday except Dec. 10, according to slides from a navigator that journalists posted on Twitter. The agency is also planning to take the exchange offline overnight during the first day of open enrollment, on Nov. 1. More than three dozen states use healthcare.gov for their marketplaces, which allow people who don’t receive insurance through a job or through a government program to buy private, tax-subsidized coverage. Navigators help people enroll in coverage and answer questions about Obamacare for potential customers. When asked about the slides, a representative from the Centers for Medicare and Medicaid Services said that “maintenance outages are regularly scheduled on healthcare.gov every year during open enrollment.” “This year is no different,” the spokesman said. A former HHS official who helped oversee previous open enrollments told the Washington Examiner that such scheduled website outages for maintenance were not the norm when Obama was in office. “This is not normal,” the former official said. “No excuse. They’re blocking people’s access to healthcare and sabotaging the law because it’s named Obamacare.”

White House legislative affairs director: Graham-Cassidy healthcare plan ‘not dead.’ Marc Short said Sunday the GOP’s latest attempt to repeal and replace Obamacare is “not dead” as the Trump administration applies pressure to win over Paul’s support. “Rand Paul’s been certainly someone who’s been very principled on healthcare and we hope we can earn his support,” Short said on “Fox News Sunday.” Short added he was confident Paul would vote for the Graham-Cassidy healthcare proposal because it provides “real entitlement reform,” gets rid of Obamacare’s individual and employer mandates, and “protects the sanctity of life.” But Short said major concessions would not be given to those who remain uncommitted “I don’t think there’s significant changes, Chris,” Short said to host Chris Wallace. “We have been continuing to talk to various senators, not just Collins and Murkowski, about ways to refine the formula because what we are actually doing, as you know, is we’re talking dollars out of Washington, D.C., and sending it out to the states.”

Democrats keep pressure on with Graham-Cassidy bill on life support. Democratic lawmakers are keeping the pressure on against the Graham-Cassidy healthcare bill. Mere minutes after McCain announced his opposition Friday, House Minority Leader Nancy Pelosi, D-Calif., sent out a “Dear Democratic Colleague” note to her caucus calling on them to continue to “highlight the devastating costs” the bill would inflict over the weekend at events in districts throughout the country. Earlier in the week, Pelosi dubbed Saturday a “day of action” for members to protest and hold rallies and predicted an “all-out mobilization” by House Democrats in the coming days. “People will be on their own because this is really organic. It’s more than us. It’s about people calling their members of Congress to say this is what this means to me,” Pelosi said Wednesday at her weekly press conference. “There will be an inside-outside mobilization to defeat the bill … Nothing is more eloquent to them than the voices of their own constituents, and that’s who they’ll be hearing from.” Sen. Kamala Harris, D-Calif., called on constituents against the legislation to keep calling and writing letters to their senators until Saturday. “Despite an attempt to appear to add money for a select few states, this bill is just as bad for those states and the rest of the states because it still contains a massive cut to Medicaid, and would throw our health insurance system into chaos while raising premiums,” Senate Minority Leader Chuck Schumer said in a statement reacting to a new draft of the bill.

Schumer says bipartisan Obamacare talks will resume. The New York Democrat praised McCain for saying he would vote against the Graham-Cassidy bill and promised to resume bipartisan negotiations to stabilize the troubled law. “John McCain shows the same courage in Congress that he showed when he was a naval aviator,” Schumer said. “I have assured Senator McCain that as soon as repeal is off the table, we Democrats are intent on resuming the bipartisan process.” Senate talks halted last week on legislation to shore up Obamacare with additional stabilizing funds.

Major healthcare groups call on Senate to reject GOP healthcare overhaul. An assembly of groups representing a wide swath of physicians, hospitals and healthcare plans issued a unified message Saturday expressing opposition to the latest Republican effort to overhaul Obamacare. “While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable healthcare market that provides access to high-quality care and affordable coverage for all. The Graham-Cassidy-Heller-Johnson bill does not move us closer to that goal,” a joint statement from the American Medical Association, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, America’s Health Insurance Plans, and the BlueCross BlueShield Association. Their message to lawmakers was clear: “The Senate should reject it.” They warned that the legislation “will cause patients and consumers to lose important protections, as well as undermine safeguards for those with pre-existing conditions. Without these guaranteed protections, people with significant medical conditions can be charged much higher premiums and some may not be able to buy coverage at all.”

Medicaid carriers add to din of opposition. A group of 14 Medicaid managed care organizations, which are insurers that process Medicaid claims, have joined the healthcare industry’s opposition to Graham-Cassidy. The carriers say the bill is “unprecedented in its effort to change the overall structure of a key American safety net,” according to the letter to Senate leadership. The carriers join an unlikely alliance of hospital, doctor and insurance groups in fighting the bill.  

Trump: ‘We still have a chance’ to pass Obamacare overhaul without McCain.  “That was a totally unexpected thing. Terrible. Honestly, terrible,” Trump said in response to McCain’s decision. “Repeal and replace. Because John McCain, you look at his campaign, his last campaign was all about repeal and replace, repeal and replace. So he decided to do something different, and that’s fine. And I say we still have a chance,” he added. “We’re going to do it eventually. We’re going to do it eventually.”

Trump shames McCain: Says he let Arizona and ‘best friend’ Lindsey Graham down. Trump attacked McCain on multiple fronts early Saturday morning. In a swath of tweets, Trump said McCain was a disappointment to his home state of Arizona and Graham, his longtime friend in the Senate. “John McCain never had any intention of voting for this Bill, which his Governor loves. He campaigned on Repeal & Replace. Let Arizona down!”, Trump said in one tweet. He added that Arizona had a 116 percent increase in Obamacare premiums last year, citing official HHS statistics. Trump also said McCain, who also voted against the “skinny” GOP Obamacare repeal in July, was influenced by Schumer, D-N.Y., which Trump called “sad.” “Great for Arizona. McCain let his best friend L.G. down!”, Trump said, a reference to Graham. After McCain came out against the latest GOP healthcare reform effort, Graham said he “respectfully disagree[s]” with his friend, adding that his effort will “press on.”

During a Friday evening rally in Alabama for Sen. Luther Strange, who faces a runoff election next week, Trump leveraged McCain’s relationship with Paul, noting how it would “ironic” if Paul replaced McCain as a yes vote for the healthcare legislation because the two “don’t like each other.”

McCain: Voting to kill ‘skinny repeal’ wasn’t about sticking it to Trump. McCain defended his vote against the Republican healthcare bill this summer, saying that his decision was not rooted in antagonism against Trump for mocking his military record. “If I took offense at everybody who has said something about me, or disparaged me or something like that — life is too short,” he said, appearing on the 50th anniversary season of CBS “60 Minutes.” “You’ve got to move on.” McCain was asked whether his “thumbs down” on healthcare should have been interpreted as a “middle finger” to Trump. “On an issue of this importance to the nation, for me to worry about a personal relationship, I’m not doing my job,” he replied. McCain said that he and Trump were “very different people” with “different upbringings” and “different life experiences.” Pressed on what he meant, McCain said, “He is in the business of making money and he has been successful, both on television as well as Miss America and others. I was raised in a military family. I was raised in the concept and belief that duty, honor, country is the load star for behavior that we have to exhibit every single day.”

McCain: ‘I am more energetic and more engaged’ because of brain cancer diagnosis. In the candid interview with “60 Minutes” about his brain cancer diagnosis, McCain said he wished to keep working as he undergoes treatment. “I am more energetic and more engaged as a result of this because I know that I’ve got to do everything I can to serve this country while I can,” said McCain, 81. He has been diagnosed with glioblastoma, a brain tumor that is one of the most aggressive forms of cancer and whose median survival time is 15 months. McCain is undergoing both chemotherapy and radiation as part of his treatment and said that during this time he will aim to “celebrate with gratitude a life well-lived.” “You know, it’s — it’s a very poor prognosis,” McCain said. “So I just said, ‘I understand. Now we’re going to do what we can, get the best doctors we can find and do the best we can.'”

Louie Gohmert: Arizona should recall McCain during cancer treatment. Rep. Louie Gohmert, R-Texas, suggested Monday that McCain be recalled because his cancer treatment may be hurting his ability to do his job in Congress. “You know, nothing inhibits recovery from cancer like stress. I think Arizona could help him and us. Recall him. Let him, you know, fight successfully this terrible cancer. And let’s get somebody in here that will keep the word he gave last year,” Gohmert told Fox News “Fox and Friends.”

Jimmy Kimmel’s fight against Graham-Cassidy aided by Schumer: Report. Late-night host Jimmy Kimmel’s recent onslaught of attacks against the Graham-Cassidy Obamacare overhaul bill was allegedly aided by Schumer, according to a report. Kimmel has been in touch with various healthcare professionals, advocacy groups, charities, and specifically, the office of Schumer, the Daily Beast reported Friday. According to a source, Schumer’s office “provided technical guidance and info about the bill, as well as stats from various think tanks and experts on the effects of [the repeal].” The latest string of attacks took place on the ABC host’s opening monologue, criticizing Cassidy for failing to uphold his promise to make sure new healthcare legislation passes what Cassidy named the “Kimmel test.” After McCain opposed the bill, Kimmel thanked McCain for being ‘a hero again and again and now AGAIN.’

Bernie Sanders: ‘Thank you, John McCain.’ Sen. Bernie Sanders gave a shout out to McCain at a rally Friday to support a government-run healthcare system, saying he wished that the Senate’s other Republicans lawmakers were more like the stubborn Arizonan. “Thank you, John McCain,” Sanders, the Senate’s only avowed socialist and a Vermont independent, said at a San Francisco rally hosted by National Nurses United, a leftist union.

Cassidy ‘disappointed’ in McCain’s opposition. The Louisiana Republican said he would continue to pursue his legislation even after losing critical support from McCain. “I am disappointed that Sen. John McCain is not voting to repeal and replace Obamacare,” Cassidy said Friday. “But, as long as there are families being penalized because they can’t afford insurance costing $30,000 to $40,000 a year, I will continue to work for those families.”

Maine plans to bring back high-risk pools. Gov. Paul LePage of Maine said Friday the healthcare bill backed by Republicans would allow Maine to re-implement a type of high-risk pool that the state had before Obamacare. “The high-risk pool was really helping lower premiums, lower the deductibles on people in Maine,” said LePage, appearing with Pence at the White House. “And unfortunately what Obamacare did is it robbed nursing homes and homecare services, and we need to go back. We’ve made those reforms.” The pools are special programs that states establish to provide a safety net for people who can’t get health insurance. The Maine program that LePage said he would want to bring back was called Public Law 90 and known as “invisible risk-sharing.” It allowed medical expenses of especially high-cost customers to be paid for without their knowing about it, with insurers responsible for a set amount of claims before the assistance kicked in. “It did not affect people’s premiums because we did it in a very innovative way, is what we call it ‘behind the curtain,'” LePage said. “People didn’t even know it. All we need to know if you had a pre-existing condition, the state took care of it.”

HHS Secretary Tom Price to stop using private jets pending reviews. Health and Human Services Secretary Tom Price has sworn off the use of a charter jet for government work pending internal reviews of department policy on the flights. “I don’t think there will be any charter trips until this review is complete,” Price said on Fox News Saturday. “I think that’s appropriate because of the concerns that we’ve heard.” Price, a former Georgia Republican lawmaker, has taken criticism across the political spectrum following reports that he chartered a private plane repeatedly at taxpayer expense, despite the availability of lower-cost commercial flights. Price’s team maintained that the $300,000 spent on private flights were necessary due to a tight schedule, but the former congressman acknowledged it was a political blunder. “The optics in some of this don’t look good,” he admitted.

Voicemails to Gov. Rick Scott from Florida nursing home where 11 died were deleted: Report. At least four voicemail messages left on Florida Gov. Rick Scott’s cell phone from the Hollywood nursing home where 11 died in wake of Hurricane Irma were deleted, according to a report. “The voicemails were not retained because the information from each voicemail was collected by the governor’s staff and given to the proper agency for handling,” a spokeswoman for the governor told CBS4 after it requested copies of the voicemails.

RUNDOWN

The Hill GOP facing likely failure on Obamacare repeal

Washington Post Here’s how Graham and Cassidy rejiggered their Obamacare overhaul

Axios Graham-Cassidy: New policies, same politics

Roll Call CHIP, FAA face deadlines this week

Wall Street Journal GOP health push hits new snags

Kaiser Health News A tale of two states: California, Texas, and the latest ACA repeal bid

LA Times California would take the biggest hit in Graham-Cassidy bill

Calendar

MONDAY | Sept. 25

New version of Graham-Cassidy bill on Obamacare overhaul expected to be released.

CBO aims to release preliminary score of Graham-Cassidy

Sept. 24-28. AHIP’s conference on Medicare, Medicaid and duals. Includes keynote by CMS Administrator Seema Verma. Details.

2 p.m. 215 Dirksen. Senate Finance Committee hearing on Graham-Cassidy bill. Details.

2 p.m. National Press Club. 529 14th St. NW. Discussion on “Mental Health and the Opioid Crisis,” with Rep. Tim Ryan, D-Ohio. Details.

5 p.m. Sen. Joe Manchin, D-W.Va., holds Facebook live town hall. Details.

9 p.m. CNN to host healthcare town hall. Details.

TUESDAY | Sept. 26

Sept. 26-28. The Atlantic Washington Ideas Forum. Includes speakers Mark Bertolini, chairman and CEO of Aetna, and Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Details.

8 a.m. Newseum. 555 Pennsylvania Ave. NW. Politico event on “The Doctor-Patient [and Government] Relationship.” Details.

8:30 a.m. 1775 Massachusetts Ave. NW. Brookings Institution event on “The Medicare Physician Fee Schedule and Alternative Payment Models.” Details.

WEDNESDAY | Sept. 27

Deadline for insurers to sign rate contracts with states.

8 a.m. Washington Court Hotel, 525 New Jersey Ave. NW. Politico event on “Aging in America.” Details.

1 p.m. Health and Human Services event on the opioid crisis titled, “Recovery, Prevention, & Hope: Live Stream Panel of National Experts on Opioids Equip Faith and Community Leaders.” Details.

3 p.m. Ronald Reagan Building and International Trade Center. 1300 Pennsylvania Ave.  Education Development Center  and the National Action Alliance for Suicide Prevention event on “From Pain to Promise – Addressing Opioids & Suicide in Communities Across America.” Details.

THURSDAY | Sept. 28

10 a.m. National Press Club. 529 14th St NW. Health and Human Services Secretary Tom Price to discuss flu prevention. Details.

FRIDAY | Sept. 29

9 a.m. 1789 Massachusetts Ave. NW. AEI event on “Unbundling and rebundling health benefits: Innovative rethinking of healthcare delivery and competition.” Details.

SATURDAY | Sept. 30

Reconciliation and CHIP reauthorization deadlines. End of federal fiscal year.