1 big thing: Medicare Advantage debate rekindled by watchdog report

2. Praise for FDA's proposed menthol ban

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3. Watch out for a blockbuster obesity drug

4. Tackling the multiple sclerosis mystery

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5. Dog of the week

Good morning. Happy Friday. It's Caitlin Owens filling in for today.

Today's word count is 794, or a 3-minute read.

Plus, support for a menthol cigarette ban

Axios Vitals: Medicare Advantage under fire

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Keep up with health care politics, policy and business

Axios Vitals

1 big thing: Partisanship undermines pandemic playbook

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2. Children's health issues getting worse

3. "Family glitch" fix on the horizon

4. As masks lift, spirits rise

5. Catch up quick

Today's word count is 987, or a 4-minute read.

Plus, we may not be learning our pandemic lessons.

1 big thing: Americans' COVID culture war

2. America's giant medical debt

3. Out-of-pocket limits aren't silver bullets

4. Having a baby isn't cheap

5. How COVID can damage the brain

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6. Dog (news) of the week

🎧 Listen: The second episode of "How It Happened: Putin's Invasion" came out this morning and features Axios world editor David Lawler, politics managing editor Margaret Talev and climate and energy reporter Andrew Freedman breaking down the consequences of the war in Ukraine.

Today's word count is 1,039, or a 4-minute read.

1 big thing: America's other public health threat

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2. Another European warning

3. A potential case of telehealth gone wrong

4. Opioid overdose rate's racial reversal 

5. While you were weekending

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Today's word count is 790, or a 3-minute read.

1 big thing: Pharmacists push for enhanced role in post-pandemic life

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2. COVID cases continue to plummet

3. New COVID funding in legislative trouble

4. Border dispute may threaten plasma supply

Today's word count is 890, or a 3-minute read.

Health Care Policy

The Republican health care agenda has shifted vastly over the last decade, moving away from program-wide overhauls to a focus on targeted changes. 

Between the lines: That shift was the intentional result of a lot of behind-the-scenes work after the last ambitious GOP effort — the effort to repeal and replace the ACA — fell apart.

I interviewed Will Dunham, Kevin McCarthy's deputy chief of staff for policy until last fall, about the thinking behind that shift. Here are the main takeaways and some of his most illuminating quotes:

1) The repeal and replace disaster was the catalyst for a caucus reset on health care. 

"After the failure to pass repeal and replace — which got out of the House, failed in the Senate — I think House Republicans started to rethink how they were talking about health care."

"It takes a lot of conversations and a lot of time for members to change the way they think and talk about a subject as broad as health. But it’s something Republicans, I think, understand is important to the American people."

"It’s a kitchen table issue, and it’s an issue I think Republicans are unwilling to cede to Democrats."

2) Republicans intentionally shifted away from a sweeping agenda and focused on finding discrete policy goals. 

"They're not proposing ... swinging for the fences, home run, grand slam, 3,000-page legislation that overhauls the health care system in the United States."

"Republicans for a long time had talked that way, and I think what Republicans realized is they were playing on the Democrats’ turf."

"That’s a playing field that Republicans are moving away from, and they're looking for singles and they're looking for doubles."

3) The targeted changes eventually adopted by the Healthy Future Task Force — a branch of the GOP's Commitment to America agenda — are designed to be meaningful to voters.

"They're looking for friction points, and they're offering solutions to alleviate friction points that Americans experience as they interact with the health care system."

4) There's no one catchphrase that can be used to sell the agenda, and that's OK with Republicans.

"Frankly, targeted reforms will not be as splashy or high profile as the kind of catchphrase health care overhauls will be — Medicare for All, et cetera. But what [they] will do is arm Republicans with discrete examples of ways they have made Americans’ lives better."  

"It's much more about communicating to constituents that we understand your problems in the health care space and we're working on fixing them in a targeted way."

5) Medicare's looming insolvency will prevent changes to the program from disappearing from the political conversation, but any changes will need to be a bipartisan effort. 

"That line, 'Save Social Security and Medicare,' was in the commitment as well. That’s something that Republicans want to do, but I think the only way you can make Medicare solvent in a durable, sustainable way is on a bipartisan basis."

"We've seen over the last decade that a partisan approach to reforming Medicare isn’t going to yield legislative results. And even if you could make law, either party, the other party would try to undo it."

Behind the GOP's pivot to the practical on health care

The party decided to go after targeted reforms after it failed to repeal and replace the ACA.

Kevin McCarthy introducing "Commitment to America" agenda in 2020.

Kevin McCarthy introduces the Commitment to America agenda in 2020. Photo: Chip Somodevilla/Getty Images

House Republicans

The Republican health care agenda has shifted vastly over the last decade, moving away from program-wide overhauls to a focus on targeted changes. Between the lines: That shift was the intentional result of a lot of behind-the-scenes work after the last ambitious GOP effort — the effort to repeal and replace the ACA — fell apart.

Axios Pro Policy

Republican doctors in Congress are increasingly becoming frustrated with the American Medical Association, citing what they call the group's "woke" policies on abortion and gender-affirming care as a turning point in their relationship. 

Why it matters: The tension could make it more difficult for Republicans and the AMA to work on less controversial and bipartisan issues such as prior authorization, physician reimbursement rates and provider mental health and burnout. 

What they're saying: Several members of the Doctors Caucus told Axios they met with AMA leadership last week.

"[W]hen they told us their priorities, they aligned with our priorities. But it's like, it doesn't look like those are your priorities. What looks like your priorities are abortion and transgender issues," said Rep. Brad Wenstrup, one of the co-chairs of the Doctors Caucus.

"It looks like all you care about are woke issues," Wenstrup said, defining the group's policies on abortion and transgender issues as "woke" because they don't align with the Doctors Caucus' "pro-life" stance and feel like a mandate to practice medicine they don't agree with.

And it's not just in the House. Sen. Rand Paul told Axios that the AMA "has been very much left-wing or left-of-center for a long time ... they are also disproportionately represented by university physicians."

"If I had time I could probably tell you 20 things the AMA has done in the last five years that I disagree with," Paul said. 

Not all Republicans are voicing such strong opinions about the AMA. "I'm a member of the AMA," Rep. Michael Burgess, another co-chair of the Doctors Caucus, told Axios. "We've all got to talk. We got a lot of problems that we have to solve." 

Zoom in: AMA issued new policies last year in response to everything from the Dobbs decision to climate change. These are dictated by a House of Delegates which votes every year on what stances the organization should take on medical issues. 

In June 2022, the AMA issued a policy stating that restricting access to abortion care is a "violation of human rights." 

In November 2022, the AMA announced new policies around abortion that included not criminalizing doctors for performing abortions, preserving access to abortion training for medical students and supporting access to abortion care. 

And it has said it opposes restrictions on transgender medical care.

The AMA has also issued policies in the last year declaring climate change a public health crisis and supporting gun reform. 

Between the lines: House Republicans have been frustrated with the AMA for a while, but things seem to have reached a breaking point in the last year. This may be part of a broader trend of the GOP cutting ties with trade associations.

"I think the AMA, it's been going on for maybe longer, but this summer when they were up on the Hill testifying about gun violence and to some extent the Dobbs decision, that might have been the end," said Joe Grogan, a USC-Schaeffer senior fellow and former Trump administration official.

Grogan pointed to how the Chamber of Commerce was traditionally linked with Republicans, but in the last year has become more aligned with Democrats due to the GOP seeing some of their policies as "too woke." 

AMA lobbyists are now "persona non grata" with member offices, said one former House Republican health staffer. 

It's beyond the AMA and extends to other professional medical groups, like the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, said Paul. 

The other side: Jack Resneck, president of the AMA, told Axios in an interview that while he knows some of AMA's policies may be seen as controversial, no doctor is likely to agree with all of the group's stances.

"With this group of physicians in Congress we do have alignment," said Resneck, who cited the prior authorization and payment rates as issues with bipartisan support. "But yes, there are going to be a few issues that we don't always agree on as well." 

"We have really strong relationships with members of Congress and I'm confident that will continue to be the case," Resneck added.  

What we're watching: One potential area of compromise is prior authorization. A bill streamlining the process in Medicare Advantage passed the House last year, and Resneck said he is hoping to work with members of Congress to introduce it again. 

GOP doctors reach breaking point with the AMA

The tensions have escalated in the last year over its policies on abortion and transgender medical care.

illustration of an elephant's foot crushing a red cross symbol 

American Medical Association (AMA)

Republican doctors in Congress are increasingly becoming frustrated with the American Medical Association, citing what they call the group&#x27;s &quot;woke&quot; policies on abortion and gender-affirming care as a turning point in their relationship. Why it matters: The tension could make it more difficult for Republicans and the AMA to work on less controversial and bipartisan issues such as prior authorization, physician reimbursement rates and provider mental health and burnout.

National

Data: OpenSecrets; Chart: Will Chase/Axios

Republicans' historical alliance with the nation's leading physicians' group has deteriorated to the point where several elected doctors are openly critical of the organization and what they refer to as its "woke" policies.

Why it matters: The fractured relationship, similar to the GOP's relationship with the U.S. Chamber of Commerce, points to a substantial change in Washington's power dynamics under a newly empowered GOP House.

Driving the news: Several GOP doctors voiced frustrations with the American Medical Association in interviews with Axios, frequently citing the organization's positions on issues like abortion and gender-affirming care. 

Some members of the congressional Doctors Caucus said they met with AMA leadership last week.

"[W]hen they told us their priorities, they aligned with our priorities. But it's like, it doesn't look like those are your priorities. What looks like your priorities are abortion and transgender issues," said Rep. Brad Wenstrup (R-Ohio), one of the co-chairs of the caucus.

Sen. Rand Paul (R-Ky.) told Axios that the AMA "has been very much left-wing or left-of-center for a long time ... If I had time I could probably tell you 20 things the AMA has done in the last five years that I disagree with."

Paul said the perception of alignment with "woke" policies extends beyond the AMA to other professional medical groups, like the American College of Obstetricians and Gynecologists — who've been leading voices on reproductive health post-Roe — and the American Academy of Pediatrics, which has been supportive of gender-affirming care.

The big picture: The fractured relationship represents major shifts within both the GOP and the AMA, including an increasing openness by the trade group to a larger role for the federal government in the health care system.

The group inveighed against "socialized medicine" for decades, opposing President Harry Truman's national health insurance plan in the 1940s, the creation of Medicare in the 1960s and President Bill Clinton's health care plan in the 1990s.

In June 2009, FiveThirtyEight reported that 64 percent of the AMA’s donations to federal candidates in the previous decade had been to Republicans. But although it opposed the inclusion of a public option in Democrats' health care plan under President Obama, the AMA eventually became a crucial supporter of the Affordable Care Act, which passed without any GOP support.

Since then,  the group opposed Republicans' repeal-replace effort in 2017. By the end of the decade, a vote by the AMA's governing body on ending the organization's opposition to single-payer health care had only narrowly failed, the New Yorker reported last year. 

But it's been the group's positions on major social issues that may have caused the most friction with congressional conservatives. 

"For a period of years, their persuasiveness with Republicans has been waning, and what has been quiet and private complaining in advance and after meetings has become open contempt for the AMA," Grogan added.

What they're saying: The organization's ideological shift has at least directionally tracked with its membership, which it says numbers more than 270,000.

“More or less over a 20-year period, a profession that was always thought of as rock-ribbed Republicans has changed, and tilted to the Democratic side,” David Rothman, a professor of social medicine at the Columbia University Vagelos College of Physicians and Surgeons, told the WSJ in 2019. 

Zoom in: AMA adopted positions last year in response to everything from the overturning of Roe v. Wade to climate change. These are dictated by a House of Delegates, which votes every year on what stances the organization should take on medical issues.

In June 2022, the AMA issued a policy stating that restricting access to abortion care is a "violation of human rights."

In November 2022, the AMA announced new policies around abortion that included not criminalizing doctors for performing abortions, preserving access to abortion training for medical students and supporting access to abortion care.

The AMA has also issued policies in the last year declaring climate change a public health crisis and supporting gun reform.

"With this group of physicians in Congress we do have alignment," said Resneck, who cited the prior authorization and payment rates as issues with bipartisan support. "But yes, there are going to be a few issues that we don't always agree on as well."

And some Republicans acknowledged the need for a working relationship with the group. "We've all got to talk. We got a lot of problems that we have to solve," Rep. Michael Burgess (R-Texas), another co-chair of the Doctors Caucus, told Axios. 

What we're watching: The tension could make it more difficult for Republicans and the AMA to work on less controversial and bipartisan issues such as prior authorization, physician reimbursement rates and provider mental health and burnout.

A version of this story was published first on Axios Pro. Get news like this by subscribing. Use code POLICY100 which gives you $100 off.

Republicans break with another historical ally: doctors

Some Republicans are now openly contemptuous of the AMA.

Health

A new bill hints at what could be the Democrats' next goal in incremental expansion of the ACA: lowering out-of-pocket costs.

Why it matters: Despite record ACA enrollment and historically low uninsured rates, millions of Americans — including those with health insurance — struggle to pay for care because they can't afford their deductibles and other cost-sharing. 

Democrats have already made ACA premium subsidies more generous since President Biden took office, and now they want to lock in those higher subsidies — and go beyond.

Driving the news: Sen. Jeanne Shaheen reintroduced legislation last week that would make the enhanced ACA premium subsidies permanent rather than letting them expire after 2025, as they would under current law. 

The bill also ties the value of the subsidies to a more generous plan, which would effectively lower enrollees' out-of-pocket costs.

Finally, it would increase the value of the ACA's cost sharing reduction subsidies for people with incomes between 100% and 250% of the federal poverty level — the currently eligible population — and make them available for people up to 400% of poverty.

The bill's cosponsors include Tammy Baldwin, Bob Casey, Tim Kaine, Amy Klobuchar, Ben Cardin and Kirsten Gillibrand — all up for re-election next year.

The big picture: Out-of-pocket costs have risen from the ACA's passage in 2010 through 2020, meaning it's common today for even covered Americans to find care unaffordable. 

A survey by the Commonwealth Fund last year found that nearly a quarter of working-age adults were underinsured, including 29% of people with employer coverage and 44% of those with coverage through the individual market.

That makes costs a ripe political target.

Yes, but: Approaches like Shaheen's don't lower underlying health care costs. Instead, they increase the level of government financial assistance. That, of course, increases the burden on taxpayers.

Democrats say the Inflation Reduction Act's prescription drug provisions demonstrate their commitment to cost containment. But that law's impact is limited to Medicare, and neither party has much of a track record of going after provider costs.

But some Democrats are hinting that they're interested in underlying cost reduction.  

“We’re going to be all about containing costs this session," Finance Chairman Ron Wyden told me when I asked him about Shaheen's bill, citing the need to give people more bargaining power to bring down their costs.

What we're watching: Shaheen's bill is unlikely to go anywhere while Republicans hold the House. But ACA incrementalism is an easy health care goal for the party to coalesce around compared with more progressive policies like Medicare for All.

So it would be unsurprising if more Democrats start messaging about the need to address cost sharing, even while avoiding some of the harder conversations about underlying prices.

Democrats' next ACA frontier: out-of-pocket costs

A new bill would lower ACA enrollees' out-of-pocket spending.

Senator Jeanne Shaheen speaks during a committee hearing

Sen. Shaheen speaks during a Senate Appropriations subcommittee hearing in February 2022. Photo: Andrew Harnik/AP Photo/Bloomberg via Getty Images

Affordable Care Act

A new bill hints at what could be the Democrats&#x27; next goal in incremental expansion of the ACA: lowering out-of-pocket costs.Why it matters: Despite record ACA enrollment and historically low uninsured rates, millions of Americans — including those with health insurance — struggle to pay for care because they can&#x27;t afford their deductibles and other cost-sharing.

Data: Committee for a Responsible Federal Budget; Chart: Axios Visuals

Negotiations to raise the country's debt ceiling will likely put Republicans in a vise, torn among competing conservative pressures, the inevitable need to work with Democrats and the realities of basic budgetary math.

The big picture: Fiscal conservatives want to balance the federal budget. Former President Trump has warned his party to leave Medicare and Social Security untouched. It’s basically impossible to do both — and every way House Republicans could try to square that circle comes with political risk.

Driving the news: House Republicans have said they’ll refuse to raise the debt ceiling unless it’s accompanied by reductions in federal spending. But the party appears to be deeply divided as to what programs should be on the chopping block.

Former President Trump warned against Medicare or Social Security cuts, urging Republicans to instead “cut waste, fraud and abuse everywhere that we can find it and there is plenty of it.”

“But do not cut the benefits our seniors worked for and paid for their entire lives. Save Social Security, don’t destroy it,” he said in a video message posted to Truth Social.

Reality check: If you take off the table cuts to Medicare, Social Security, veterans and defense spending, and if you’re also not going to raise taxes to bring in more revenue, you’d need to cut about 85% of the rest of the budget in order to make it balance, according to a recent analysis by the Committee for a Responsible Federal Budget.  

“​​The numbers can’t work,” said Chris Campbell, a former Treasury official and GOP Finance Committee aide.

That sets up a scenario in which either moderates or conservatives will have to cave in order to pass anything just through the House — never mind getting it through the Democrat-controlled Senate and White House.

State of play: Conservatives have said they secured a commitment from House Speaker Kevin McCarthy  to create a budget that balances over the next decade, an exercise that would likely precede a vote on the debt limit.

McCarthy reportedly agreed to freeze discretionary spending at 2022 levels, which has already rankled some GOP members who worry that would effectively mean less Pentagon funding.

Some conservatives have said defense cuts weren't part of the deal. Republicans could theoretically get to 2022 spending levels just through non-defense spending cuts.

The looming question is which cuts included in a budget would then be included in House Republicans' debt limit demands.

“This is shaping up to be a tough vote to balance in 10 years,” said a former House GOP leadership aide. “Where are the cuts going to be? Is it going to be on defense, entitlements or both? Both could cause problems.”

The intrigue: The House could always fake it. Budget resolutions are just frameworks; they don't become law. So the House GOP could pass a non-binding budget that includes steep cuts, then pursue only modest reductions when it’s time to actually set federal spending levels and negotiate over the debt ceiling.

But some hardliners will push for the biggest cuts to be real. 

Flashback: Former Rep. Paul Ryan's 2012 plan to partially privatize Medicare only ever existed in a non-binding budget resolution — you don't have to actually make the cuts in order to open yourself up to a barrage of attack ads.

“You’ve got to protect Medicare and Social Security. And the path the Democrats are going, they are going to go bankrupt,” McCarthy recently told reporters, per the Washington Post. 

“Let’s sit down and find a place that we can protect Medicare and Social Security for the future generations, let’s put our house in order on how we’re going to spend, and let’s make the investments we need to make America stronger.”

What they’re saying: Most ultra-conservative members represent safe congressional districts, giving them little incentive to compromise. More moderate members in swing districts will likely want to take fewer political risks.

“For those committed conservatives, they have a little more wiggle room than the more moderate members of...the Republican party, where the voters tend to be a little less forgiving on some positions that can be seen as — and would be characterized by Democrats, I’m sure — as extreme,” Campbell said.

Kevin McCarthy's math problem

It's nearly impossible to balance the budget without cutting Medicare or Social Security spending

Size of spending cuts necessary to balance the budget

Policymaking

Negotiations to raise the country&#x27;s debt ceiling will likely put Republicans in a vise, torn among competing conservative pressures, the inevitable need to work with Democrats and the realities of basic budgetary math.The big picture: Fiscal conservatives want to balance the federal budget. Former President Trump has warned his party to leave Medicare and Social Security untouched. It’s basically impossible to do both — and every way House Republicans could try to square that circle comes with political risk.

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Caitlin Owens

Stories

Republicans break with another historical ally: doctors

GOP doctors reach breaking point with the AMA

Democrats' next ACA frontier: out-of-pocket costs

Kevin McCarthy's math problem

Behind the GOP's pivot to the practical on health care

Newsletter editions

Axios Vitals: Medicare Advantage under fire

Axios Vitals: Children's health crises

Axios Vitals: Another looming threat

Axios Vitals: Massive medical debt

Axios Vitals: COVID response imperiled