Daily on Healthcare: Trump resurrects repeal and delay…Centene fills the 25 ’empty’ counties in Missouri

Trump resurrects repeal and delay: On Friday, with the Republican healthcare drive stalled inside the red zone, Trump rocked Washington by tweeting, “If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!” Sen. Ben Sasse, R-Neb., sent a letter to Trump Friday morning urging the White House to adopt a two-step strategy in which conservative senators focus on repealing the Affordable Care Act now. Sasse said Republicans do not appear to have the votes to pass the current bill and should focus on following through on the campaign promises both Trump and congressional Republicans touted. Meanwhile, Sen. Rand Paul tweeted, “I have spoken to President Trump & Senate leadership about this and agree. Let’s keep our word to repeal then work on replacing right away.”

The sound you hear is staffers for Senate Majority Leader Mitch McConnell breaking stuff. Going into 2017, Republican leadership had planned a quick-strike strategy to repeal Obamacare within weeks of President Trump taking office by passing an updated version of the repeal bill that the GOP Congress had already passed and former President Barack Obama vetoed. The implementation of the repeal would then be delayed as Republicans negotiated a plan to replace it. But the idea drew wide criticism and collapsed largely because Paul effectively convinced Trump that it would be better to do repeal and replace simultaneously. McConnell and House Speaker Paul Ryan begrudgingly abandoned “repeal and delay” and worked to hash out details of one piece of legislation that would have elements of both repeal and replace. Now McConnell is struggling to get into the end zone, as centrists and conservatives pull the bill in different directions. As tempting as the “repeal and delay” strategy may sound, it always had complications, including the uncertainty for individuals and insurance markets about what would take its place. Based on what we’ve witnessed over the past several months, the repeal-first strategy seems even less likely to succeed. Negotiations have exposed that a critical mass of Republicans do not have the stomach to repeal Obamacare — even lawmakers who voted in favor of repeal in the past. For instance, Sen. Shelley Moore Capito, R-W.Va., voted for the 2015 repeal bill, which would have entirely repealed Obamacare’s Medicaid expansion within two years. Now she’s flinching at supporting a Senate bill that spends a trillion dollars on subsidizing insurance coverage and propping up markets, that never formally repeals the Medicaid expansion, and doesn’t fully defund the expansion for seven years. Could we imagine the likes of Capito, Sens. Dean Heller and Susan Collins, now embracing a repeal-only bill?

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Conservative groups back repeal first strategy: Conservatives cheered Trump’s tweet Friday morning. “It’s good to see the president joining us in terms of full repeal effort at this stage,” said Ken Cuccinelli, the president of the Senate Conservative Fund PAC, on a call with several groups Friday. Freedomworks President Adam Brandon released a statement supporting full repeal of Obamacare, pointing out that House and Senate Republicans voted for a such a bill in 2015, under the Obama administration. “Virtually every Republican has campaigned on repealing Obamacare for the better part of a decade … This is the one aspect of this on which conservative grassroots activists and Republicans agree. We can come back later and work on patient-centered, free market-based replacement provisions.” Former Sen. Jim DeMint, who recently was removed as president of the Heritage Foundation agreed:  “The only way to get this done now is to repeal first, come back and begin to improve our current system.” Andy Roth of the Club for Growth said he wants to put a repeal bill up for a vote and dare moderates to vote against it. “The entire problem with the House bill and the Senate bill is that full repeal was never considered,” he said. “Moderate Republicans have fundamentally lied to the voters about their true positions.” He also said any repeal bill needed to fully gut the law’s regulations. “We do not want to do partial repeal now, leave the regulations in place and allow moderates and Democrats to conspire to pass a replacement,” he said.

Republicans wish Trump would use the Obamacare bully pulpit. Members of Congress and top strategists said Trump’s limited public engagement is hampering their ability to corral votes for their bill in the Senate. They conceded, with disappointment, that his effort pales in comparison to what former President Barack Obama did to push the Affordable Care Act across the finish line. “Absolutely, there’s more he could be doing,” a Republican senator told the Washington Examiner. “Tweeting about Mika is not as effective as tweeting about lowering premiums and deductibles.”

Senators flirt with bipartisanship on healthcare bill. Republicans have vowed for seven years to repeal and replace Obamacare, but in light of dire projections the drafted GOP healthcare bill would have on uninsurance rates and Medicaid cuts, a single Republican is publicly calling more strongly for an entirely different approach: Fix Obamacare rather than gut it and do so by working with Democrats. The centrist Republican, Sen. Susan Collins from Maine, made the suggestion Monday on Twitter, after a Congressional Budget Office report projected that the bill, the Better Care Reconciliation Act, by 2016 would cut Medicaid by $772 billion and cause 22 million more people to become uninsured. “I want to work w/ my GOP & Dem colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won’t do it. I will vote no on mtp,” she said. Democrats have said that they are open to fixes to Obamacare, though they have said that repeal is a nonstarter for them and have focused their messaging on defending the law rather than unifying behind specific policies that would lead to improvements. On the Senate floor Wednesday, however, Senate Minority Leader Chuck Schumer, D-N.Y., called for Republicans to “start over” on healthcare and instead take a bipartisan approach.

But changes are still being negotiated. GOP leaders are strongly considering an amendment from Texas Sen. Ted Cruz to let insurers sell plans that don’t comply with Obamacare’s insurance mandates as long as they sell some plans that do. The idea behind the amendment is to address conservative concerns that the bill doesn’t repeal enough of Obamacare’s insurer mandates that conservatives say are driving up premiums. However, it is not clear how the amendment would spread risk among the people buying the Obamacare plans and the likely cheaper plans that don’t comply with Obamacare.

Senators also target healthcare bill’s tax cut for wealthy. More Republican senators say they are willing to keep an Obamacare tax on investments for wealthy people as a way to fund changes to the Senate healthcare legislation. However, conservative senators remain resistant and say they want all of the law’s taxes to go. At issue is a 3.8 percent tax on investments for people making more than $250,000 a year. The bill would eliminate the tax, alongside all of the other Obamacare taxes, but has opened up Republicans to attacks from activists and Democrats who say they support a tax break for millionaires. Senators looking for more money to boost tax credits or Medicaid are looking at keeping the tax and are gaining traction in the GOP conference.

Sen. Shelley Moore Capito still a ‘no’ on healthcare bill, despite opioid funding boost. Sen. Shelley Moore Capito suggested Thursday that the $45 billion in funding to fight opioid addiction added to the Republican healthcare bill would not be adequate on its own to win her support for the legislation. “We’ve been pushing hard for the extra opioid money and it’s critical,” the West Virginia Republican told reporters. “Is it enough to push me into the yes? Not at this point.” Capito’s West Virginia Democratic counterpart, Sen. Joe Manchin, also a centrist, called the funding for opioid treatment “terrific,” but said it was inadequate in covering other provisions offered through Medicaid.  “We need money to fight opiate,” Manchin said. “But I can’t throw grandma out of the nursing home, and I can’t do away with all the other things for us to sell our soul on one issue.”

CBO: Senate bill cuts Medicaid spending by 35 percent in coming decades. The estimate released Thursday aims to provide a longer view of how the Senate bill’s Medicaid reforms would affect the low-income healthcare program. It is in addition to an earlier score that found the bill would cut Medicaid by $772 billion through 2026. The CBO found that Medicaid spending would grow 5.1 percent each year under current law over the next two decades partly because healthcare costs will continue to increase. However, under the Senate bill, Medicaid spending would increase only 1.9 percent per year through 2026 and about 3.5 percent per year in the decade after that, the CBO said.

White House pushes back on CBO claims of 15 million uninsured next year. In a call with reporters Thursday, Health and Human Services officials said they expected that 2 or 3 million more people would be uninsured because they believe people will sign up for plans that are less expensive. The Senate bill would allow states to change some of the insurance protections Obamacare provides, which would reduce prices but may leave people without adequate coverage for needs they don’t anticipate. The CBO report had projected that 15 million people would be uninsured next year, mainly because the individual mandate would be repealed. “I think there is significant skepticism about the power of the individual mandate,” a senior HHS official said. The officials also said that CBO began its analysis assuming that 18 million would have exchange enrollment, but noted that number is actually closer to 10 million.

Trump nominates Indiana health chief as new surgeon general. If Indiana health commissioner Jerome Adams wins Senate confirmation, he would succeed Dr. Vivek Murthy as the nation’s top doctor. Murthy, who was appointed by former President Barack Obama, was removed from the post in April. Adams was appointed to his Indiana post by Vice President Mike Pence when he was governor of Indiana. Adams was appointed in fall 2014 right before a major outbreak of HIV connected to needle use from opioid abuse in rural Indiana. Pence was criticized for taking too long to set up a needle exchange to help alleviate the crisis. Adams took on the criticism in an opinion piece in the New England Journal of Medicine in 2015. “Effective needle-exchange programs constitute only part of an array of necessary services that can be scarce in rural communities,” he wrote.

Centene fills the 25 ’empty’ counties in Missouri. The company will be selling plans on the Obamacare exchange in Missouri in 40 counties overall that will cover customers in 2018. The state’s insurance commissioner said in a statement that it had been working to fill the empty counties. “Our collaboration with Centene and other local stakeholders reflects the strength and leadership of state-based regulation in solving problems for our fellow citizens,” said Chlora Lindley-Myers, Missouri’s insurance director.  According to the Kaiser Family Foundation, 36 U.S. counties are still facing the prospect of having no insurers to receive tax-subsidized plans from next year, in Ohio, Nevada and Indiana. Currently, 23,393 customers are signed up for these plans.​
 

RUNDOWN

Politico Dazed GOP bolts Washington in healthcare disarray

Axios Senate health bill: Mission accomplished?

Bloomberg Popular cancer pill goes generic, yet patients’ costs stay high

New York Times There’s only one grocery story in rural areas. Should we expect two health insurers?

Roll Call GOP wheeling and dealing take center stage in the Senate

The Hill GOP leaders prepared to make big boost to healthcare innovation fund

STAT News Their children are dying. So these families are racing to raise money for research no one else will fund

Wall Street Journal How the proposed healthcare bill will affect your taxes

Tech Times New fentanyl strains are resistant to opioid overdose antidote Narcan

Reuters Ohio lawmakers vote to freeze Medicaid expansion

Calendar

FRIDAY | JUNE 30

Congress on Fourth of July Recess.

June 30-July 3. Marriott Marquis San Diego Arena. San Diego. Annual conference for the National Association of School Nurses. Details.

TUESDAY | JULY 4

Fourth of July holiday.

WEDNESDAY | JULY 5

6 p.m. 1900 Gateway Blvd, McKinney, Texas. Sen. Ted Cruz holds town hall with Concerned Veterans of America. Details.

THURSDAY | JULY 6

11:30 a.m. CST/12:30 a.m. EST. McKenna Youth and Activity Center. 311 Main St, Palco, Kan. Sen. Jerry Moran, R-Kansas, to hold a town hall. Details.

6 p.m. 9721 Arboretum Blvd, Austin, Texas. Sen. Sen. Ted Cruz holds town hall with Concerned Veterans of America. Details.

FRIDAY | JULY 7

Noon. G50 Dirksen. Alliance for Health Policy and the Commonwealth Fund event on “Understanding What’s Next for Medicaid.” Details.