The odds are against a simple ACA stabilization bill

Why Alexander doesn’t feel better about the markets

Price's rule would boost payments for medical equipment

What happens to privacy rules in a hurricane

Pacemakers are now less likely to get hacked

Why physicians aren’t ready for Medicare payment changes

Good morning ... There's nothing easy about putting together a simple Affordable Care Act stabilization bill, as Sens. Lamar Alexander and Patty Murray are about to find out. And it looks like there's a pay boost in the works for medical equipment suppliers.

Looking for more options to help the Hurricane Harvey recovery? Here's a great list by the Texas Tribune.

What we're watching this week: Govs. John Kasich and John Hickenlooper release ACA stabilization plan. Expected late in the week.

What we're watching next week: Senate HELP Committee hearings on bipartisan ACA stabilization bill, Sept. 6 and 7; markup of Senate funding bill for HHS, dates TBD.

What we're watching in September: Senate Finance Committee hearing on CHIP reauthorization. Also, Healthcare Security Forum, sponsored by the Healthcare Information and Management Systems Society, Sept. 11-13.

The hotline is still open for tips and feedback: david@axios.com.

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Keep up with health care politics, policy and business

Axios Vitals

Lessons for the next act on health care

How Alexander and Murray will get senators on board

About those HHS advertising cuts...

The looming Tar Heel health care giant

The Kasich-Hickenlooper tradeoff

Medigap changes are coming

Thanks for reading!

Happy Friday, and this is it — my last issue of Vitals! But not to worry. I'm passing the torch to Sam Baker next week (after the holiday weekend on Tuesday), and you will be lucky to have him in your inbox every morning because he will make Vitals better, smarter, and faster.

Thanks to all of your for your time and attention, and please encourage all of your friends to sign up as Sam reboots the franchise. I'll start a broader role at Axios next week, so keep in touch and let me know what we can do better: david@axios.com.

What we're watching next week: Senate HELP Committee hearings on bipartisan ACA stabilization bill, Sept. 6 (insurance commissioners) and Sept. 7 (governors). 2017 Wells Fargo Healthcare Conference in Boston, Sept. 6-7; Senate Finance Committee hearing on CHIP reauthorization, Sept. 7; markup of Senate funding bill for HHS, dates TBD.

Also, Kasich and Hickenlooper discuss their ACA proposal at a joint American Enterprise Institute-Center for American Progress event, Sept. 8. RSVP here.

What we're watching in two weeks: Senate HELP Committee hearings on bipartisan ACA stabilization bill, Sept. 12 and 14. Also, Healthcare Security Forum, sponsored by the Healthcare Information and Management Systems Society, Sept. 11-13.

The cancer drug pricing firestorm

What Tennessee’s insurance commissioner wants

How to keep ACA stabilization narrow

Maine governor wants to call Medicaid expansion “welfare"

Medicare’s hospital data dump

Good morning ... Quick reminder that the Sam Baker era of Vitals begins next week. I'll hand off to him after Labor Day, and he'll guide you through the next big stories in health care politics, business, and technology. I'll still pop up from time to time, probably in flashbacks or maybe a dream sequence.

What we're watching today: Govs. John Kasich and John Hickenlooper are expected to release their ACA stabilization plan.

What we're watching next week: Senate HELP Committee hearings on bipartisan ACA stabilization bill, Sept. 6 and 7; 2017 Wells Fargo Healthcare Conference in Boston, Sept. 6-7; markup of Senate funding bill for HHS, dates TBD.

Let me know what we missed: david@axios.com.

No “bare counties” doesn’t mean no problems

Here’s why pharmaceutical advertising is skyrocketing

Uninsured rate falls — just a bit

Gilead’s expanding portfolio of expensive drugs

How Harvey will affect health care providers

Drug price lawsuit against CVS is dropped

Good morning, and let's start with a bit of news: It's my last week writing Vitals! Starting next week, Sam Baker will be your host. He's got that rare ability to make you smarter about health care, even the wonkiest parts, while keeping it quick, easy and fun. Vitals 2.0 will be way better, so now's the time to get all of your friends to sign up.

And don't worry, I'm not going anywhere. I'll still be editing and contributing to Vitals — while taking a broader role to work across all areas of Axios coverage. So with that, here's the health care news you need to know.

What did we miss? Lemme know: david@axios.com.

What could happen next on ACA taxes

Pharma leads profitable second quarter for health care

Why narrow networks matter in hurricanes...

...and why employers want more of them

While we were week-offing...

Good morning ... Vitals is back, and I wish we were coming back to better news. Hoping my Texas friends are safe and dry, and with power. If you're looking for ways to help, Texas Gov. Greg Abbott and city leaders say the American Red Cross is your best bet: www.redcross.org, or 1-800-RED-CROSS. (You can make a $10 donation by texting HARVEY to 90999.)

Meantime, we've got a look at why a delay in Affordable Care Act taxes is considered a must-do by industry lobbying groups, and yet there's no clear path forward.

Let me know what else is at the top of your post-Labor Day health care list: david@axios.com.

National

Data: Axios-Ipsos poll; Table: Simran Parwani/Axios

Republicans see fentanyl and other opioids as the biggest threat to Americans’ public health, while Democrats say it's guns, according to a new Axios-Ipsos survey.

Why it matters: The Axios-Ipsos American Health Index sheds light on how our partisan divisions — and our education levels — play into the wrangling over public health policies, and how they guide the parties' political messaging.

The survey also found that Americans overwhelmingly want private health insurance companies to cover weight-loss drugs and that they support capping out-of-pocket insulin costs at $35 per month.

Nearly half of Americans — 47% — say insurers should cover transgender-related medical care. That's a deeply partisan issue: 77% of Democrats favor it; just 16% of Republicans do.

"Like everything else, public health is a tale of two Americas — one red, one blue," said Cliff Young, president of Ipsos U.S. Public Affairs. "Governments must be nimble to talk about multiple public health issues at once."

The big picture: The national survey of 1,213 U.S. adults found that Americans' concerns over opioids — including fentanyl, a synthetic — vary by education level, not just by party.

Opioids were the top health concern of 32% of people with a high school diploma or less, compared to 25% of people with some college and 20% of those with a bachelor's degree or higher.

Concerns about obesity appear to correlate to education: Just 12% of Americans with no college — but 30% of those with a bachelor’s degree or higher — say it's the nation's biggest public health threat.

There's a big divide among those worried about guns, based on where they live: 22% of urban residents and 17% of suburban residents cited gun violence as their biggest concern, compared to just 8% of rural Americans.

Reality check: Heart disease and cancer actually were the two leading causes of death in the U.S. as of 2021, followed by COVID-19 and accidents, according to the Centers for Disease Control and Prevention (CDC).

But in the survey about Americans' health concerns, cancer ranked a distant fourth, with coronavirus, unsafe roads or driving, smoking and tobacco products, and alcohol abuse next in line.

Context: The findings square with the priorities lawmakers are pursuing on Capitol Hill. A House Energy and Commerce subcommittee kicked off the year under the new Republican majority with a hearing focused on fentanyl, while House Democrats have asked for a classified briefing on mass shootings.

Both sides are responding to grim statistics: The CDC estimates there were 107,477 drug overdose deaths in the 12 months ending in August 2022, while gun violence killed more than 44,000 Americans last year.

The survey also is a window into President Biden's thinking when he proposed limiting insulin costs to $35 a month, a popular plan roundly praised by Democrats in Congress — and criticized by Republicans.

By the numbers: 26% of Americans overall see opioids as the greatest current threat to U.S. public health — the largest share of any concern cited.

Republicans were more than twice as likely to say so as Democrats, with independents falling somewhere in the middle.

Obesity, at 21% among Americans overall, is seen as the second-largest threat. Republicans and independents are more concerned than Democrats about the issue.

Access to guns or firearms is seen as the third highest public health threat by Americans overall, at 17%, but that belies a gaping partisan disconnect: Democrats are nearly nine times as likely as Republicans to say it's the biggest threat.

Between the lines: Despite the differences in priorities, majorities of Americans said they support stricter requirements for guns, including majorities across the political spectrum and among gun owners.

37% said they or someone in their household owns a gun.

The survey found that 87% of Americans support background checks for all gun sales, with 97% of Democrats, 79% of Republicans and 88% of independents endorsing the idea.

Likewise, 78% of Americans support red-flag laws to allow guns to be taken away from people who courts have determined to be dangerous, including 95% of Democrats, 63% of Republicans and 79% of independents.

And 84% of Americans — including 73% of gun owners — said they'd support requiring gun owners to keep their firearms stowed with trigger locks or in safes. 

Methodology: This Axios/Ipsos Poll was conducted Feb. 17-21 by Ipsos' KnowledgePanel®. This poll is based on a nationally representative probability sample of 1,213 general population adults age 18 or older.

The margin of sampling error is ±3.0 percentage points at the 95% confidence level, for results based on the entire sample of adults.

Editor's note: This article was updated with a quote from Ipsos.

per the Centers for Disease Control and Prevention

Axios-Ipsos poll: Republicans call opioids No. 1 health threat

Democrats see guns as the biggest threat to Americans’ public health, while Republicans say it’s fentanyl and opioid addiction.

Axios-Ipsos Coronavirus Index

Politics & Policy

Data: Axios/Ipsos; Chart: Tory Lysik/Axios

Nearly four out of 10 Republicans and one in four Democrats say they'll blame election fraud if their party doesn't win control of Congress in November, in the latest wave of the Axios-Ipsos Two Americas Index. 

Why it matters: A month out from the 2022 midterms, 2020's Big Lie is alive and morphing into a broader distrust of institutions and elections that threatens to become entrenched.

By the numbers: Republicans surveyed are significantly more likely than Democrats not only to predict that election fraud will play some role if their party loses, but to feel that suspicion intensely.

One in five Republicans said it would be "highly likely" for election fraud to explain why their party wouldn't take over control of Congress, compared to one in 10 Democrats who said they'd feel that way if they lose.

In addition, Democrats were more likely than Republicans to dismiss the likelihood of fraud completely.

60% of Democrats said fraud is unlikely to be the reason if their side loses (15% said they don't know), while 36% of Republicans said fraud is unlikely to be the reason if they lose (26% said they don't know).

The intrigue: The survey found that Americans who'd shared at least one meal in the past month with others from different political affiliations would be more skeptical about jumping to conclusions that election fraud caused a loss. 

What they're saying: "When you have connections across the aisle with other people, you’re less likely to give into or even entertain some of the 'crazy,'" said Ipsos pollster and senior vice president Chris Jackson.

"There are so few of those connections remaining, and that lack of connection contributes the space for people to believe the Big Lie and that elections are going to be stolen and all those kinds of things. Because they’re believing it about someone they’ve never met," Jackson said.

The big picture: Respondents were split on the generic ballot question, with 35% saying they intend to vote for Democratic candidates and 31% saying they plan to vote for Republican candidates. Across the aisle, motivations were more positive than negative.

69% of those planning to vote for Democrats said they're driven by support of Democratic candidates and their policies, with 27% motivated by opposition to Republicans and their policies.

65% backing Republicans affirmatively support GOP people and ideas while 30% are driven by opposition to Democrats and their policies.

One-third overall say when they think about the congressional election they feel hope — about twice the share who say they feel dread.

43% of respondents said former President Trump is unfairly targeted by the left, while 45% disagreed. The results were split predictably along party lines.  

Methodology: This Axios/Ipsos Poll was conducted Sept. 28-29 by Ipsos on their online survey panels in English. This poll is based on a sample of 1,004 general population adults age 18 or older, weighted on age, gender, race/ethnicity, education, and location to be nationally representative.

The margin of sampling error is ±3.8 percentage points at the 95% confidence level, for results based on the entire sample of adults.

Two Americas Index: Must be fraud

Nearly four out of 10 Republicans and one in four Democrats say they'll blame election fraud if their side loses.

Midterm elections 2022

Midterm Elections 2022

Nearly four out of 10 Republicans and one in four Democrats say they&#x27;ll blame election fraud if their party doesn&#x27;t win control of Congress in November, in the latest wave of the <a class="gtmContentClick" data-vars-link-text="Axios-Ipsos Two Americas Index" data-vars-click-url="https://www.ipsos.com/en-us/news-polls/axios-ipsos-two-americas-index" data-vars-item="in_content_link" href="https://www.ipsos.com/en-us/news-polls/axios-ipsos-two-americas-index" target="_blank">Axios-Ipsos Two Americas Index</a>. Why it matters: A month out from the <a class="gtmContentClick" data-vars-link-text="2022 midterms" data-vars-click-url="https://www.axios.com/politics-policy/midterm-elections-2022" data-vars-item="in_content_link" href="https://www.axios.com/politics-policy/midterm-elections-2022" target="_self">2022 midterms</a>, 2020&#x27;s Big Lie is alive and morphing into a broader distrust of institutions and elections that threatens to become entrenched.

Note: Respondents could choose up to two answers out of 10 options. Data: Axios/Ipsos Poll; Chart: Jared Whalen/Axios

Americans' most common worry if Democrats keep control of Congress is the economy worsening, while concerns about a GOP takeover are more divided, according to an Axios-Ipsos poll.

Why it matters: If the economy and inflation are on voters' minds more than other issues come November, the burden will fall on President Biden and his party.

It will likely be easier for Republicans to mobilize voters around those concerns than for Democrats to focus on any particular case against Republican control.

Americans' concerns about Republicans are divided among the economy, President Biden being blocked from getting things done, and too much focus on divisive social issues and election conspiracy theories.

What they're saying: "The economy remains the single biggest issue facing the country. That puts added pressure on the Democrats and President Biden for what happens with the economy," said Ipsos vice president Mallory Newall.

"If things get worse, the public will hold them accountable."

Another warning sign for Democrats, according to Ipsos senior vice president Chris Jackson: "Democratic support for Democrats is pretty tepid, whereas Republican opposition to Democrats is solid."

Between the lines: Overall, voters aren't significantly more worried about Democrats keeping control of Congress or Republicans winning it. What worries them most is a divided government, which could happen if Republicans win the House but Democrats keep the Senate.

53% say they would be worried about one party controlling the Senate and the other controlling the House.

By contrast, 49% said they'd be worried about Democrats keeping control of Congress, while 46% said they'd be worried if Republicans win both the Senate and the House.

If Democrats keep control of Congress, more than four in 10 respondents — 43% — said they'd be worried about the economy or inflation getting worse

That's largely driven by Republicans (64%), but 38% of independents share that concern.

By comparison, just 18% worry that Democrats would spend too much time investigating former President Trump; 18% fear there would be no checks on Biden's power; and 16% are concerned that Americans' confidence in government would decline. 

If Republicans gain control, people would have several concerns of roughly equal weight:

24% say they're concerned that the economy or inflation could get worse, while 23% worry that Biden won't be able to get anything done.

21% are concerned Republicans would spend too much time on divisive social issues — which likely reflects a concern about abortion, according to Newall. (13% raised that concern about Democrats if they keep control.)

In addition, 19% worry that political violence will increase if Republicans win Congress. 18% say Trump's claims of election fraud could gain more traction, and 17% say Americans' confidence in the government could decline.

Methodology: This Axios/Ipsos Poll was conducted Sept. 23-26 with a national sample of 1,004 general population adults age 18 or older, randomly drawn from Ipsos' online panel, partner online panel sources and "river" sampling.

The poll has a credibility interval of ±3.8 percentage points for results based on the entire sample of adults.

Axios/Ipsos poll: Midterms warning for Democrats

Many Americans worry that the economy could get worse if they keep control of Congress.

Deep Dive - 2022 midterms

Americans&#x27; most common worry if Democrats keep <a class="gtmContentClick" data-vars-link-text="control of Congress" data-vars-click-url="https://www.axios.com/politics-policy/midterm-elections-2022" data-vars-item="in_content_link" href="https://www.axios.com/politics-policy/midterm-elections-2022" target="_self">control of Congress</a> is the economy worsening, while concerns about a GOP takeover are more divided, according to an <a class="gtmContentClick" data-vars-link-text="Axios-Ipsos poll" data-vars-click-url="https://www.ipsos.com/en-us/news-polls/americans-worried-midterms-could-bring-divided-government-gridlock" data-vars-item="in_content_link" href="https://www.ipsos.com/en-us/news-polls/americans-worried-midterms-could-bring-divided-government-gridlock" target="_blank">Axios-Ipsos poll</a>.Why it matters: If the economy and inflation are on voters&#x27; minds more than other issues come November, the burden will fall on President Biden and his party.

More than 200 election deniers — candidates promoting baseless claims that the 2020 election was stolen from former President Trump — will appear on November general election ballots across the U.S.

Why it matters: Those who win will gain footing to affect future elections including the 2024 presidential race — through court challenges, administrative actions, executive orders, legislation, radical interpretation of law or the refusal to certify valid results, elections experts tell Axios.

Here's how the following offices could matter if they're won by election deniers.

Secretaries of state — They matter because they're the chief election officers in 24 states where they're elected by the voters, and in four others where they're appointed by the governor, according to the National Conference of State Legislatures. 

That would give election deniers enormous potential power to administer elections based on their false claims about the 2020 election — or refuse to stand up to pressure to change election results.

"The secretaries of state are key and no one knows about them," said New York University's Ruth Ben-Ghiat, author of "Strongmen: Mussolini to the Present." "These are figures who work in the background if democracy is robust."

Governors — A governor who disputes the 2020 election results can appoint chief election officials in five states (Florida, New Jersey, Pennsylvania, Texas and Delaware), according to NCSL. 

That would become an issue in Pennsylvania, where Republican nominee Doug Mastriano has talked about the importance of his secretary of state pick as he spreads false claims about the 2020 election.

The governor can also refuse to certify election results, as Kari Lake, the Republican nominee in Arizona, says she would have done with that state's results in 2020. 

Attorneys general — This office matters because a state attorney general can file lawsuits based on bogus stolen election claims, as Texas' Ken Paxton did in a lawsuit that was rejected by the Supreme Court.

House and Senate: They can certify a state's presidential election results in 2024 — or, as we saw in 2020, they can object and potentially throw an orderly presidential transition into chaos.

The bottom line: These offices are all important in making democracy work, but they're not the only ones that could matter if they fall into the hands of people who reject election results when they don't like the outcome.

"There are lots of places where people who don’t act in good faith could attempt to subvert election results," said Rick Hasen, an election law expert and director of UCLA Law's Safeguarding Democracy Project. "It could be down to poll workers in a precinct or a governor who signs a bogus certification of electors."

"The point is that our decentralization [of voting], which serves to be a strength in some ways, can also turn to be a weakness."

Election denial: The offices that matter

Here's how candidates who baselessly dispute the 2020 election results could gain power.

Illustration of a hand holding a pen with abstract ballot elements in the background.

More than <a class="gtmContentClick" data-vars-link-text="200 election deniers" data-vars-click-url="https://www.axios.com/2022/09/18/donald-trump-election-deniers-2024" data-vars-content-id="d2516181-1196-4aed-984d-738603f56073" data-vars-headline="Election denial: The offices that matter" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2022/09/18/donald-trump-election-deniers-2024" target="_self">200 election deniers</a> — candidates promoting baseless claims that the 2020 election was stolen from former President Trump — will <a class="gtmContentClick" data-vars-link-text="appear on November general election ballots" data-vars-click-url="https://projects.fivethirtyeight.com/republicans-trump-election-fraud/" data-vars-content-id="d2516181-1196-4aed-984d-738603f56073" data-vars-headline="Election denial: The offices that matter" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://projects.fivethirtyeight.com/republicans-trump-election-fraud/" target="_blank">appear on November general election ballots</a> across the U.S.Why it matters: Those who win will gain footing to affect future elections including the 2024 presidential race — through court challenges, administrative actions, executive orders, legislation, radical interpretation of law or the refusal to certify valid results, elections experts tell Axios.

Health Care Policy

President Biden released a Medicare plan early Tuesday that he says would extend the program's solvency by 25 years — by taxing high-income people more and expanding the Democrats' prescription drug negotiation program.

Why it matters: It's a sneak peek at his fiscal 2024 budget plan before the rest comes out Thursday. And like most presidential budgets, you should read it for the clues about his positioning rather than preparing for it to sail through Congress.

The Medicare tax rate for earned and unearned income above $400,000 would jump from 3.8% to 5%.

The budget would close what the White House calls "loopholes" by making sure wealthy people can't shield any of their income from high-income Medicare taxes, and dedicate the revenue to the Medicare Trust Fund.

The new Medicare prescription drug negotiation program would be expanded by allowing negotiations on more drugs, starting sooner after the drugs hit the market, and the savings would be used for the Medicare trust fund.

Biden wants to cap Medicare Part D cost-sharing at $2 per prescription per month for some generic drugs, like those used for hypertension or high cholesterol.

He also wants to get rid of Medicare cost-sharing for three mental or behavioral health visits per year and aim for parity between Medicare physical health and mental health coverage.

And, of course, the White House wants everyone to know that when Medicare can negotiate the prices of more drugs, it "will not only save money for the federal government, it will also cut beneficiary's out-of-pocket costs by billions of dollars," as the fact sheet puts it.

Our thought bubble: Is it a House Republican-friendly budget? Of course not. But you knew that.

Will it allow Biden to counter any GOP calls to cut or otherwise change Medicare to extend its solvency? Mission accomplished.

Biden's tax-the-rich Medicare plan

His budget would extend Medicare solvency through taxes and more drug price negotiations.

Medicare

President Biden released a Medicare plan early Tuesday that he says would extend the program&#x27;s solvency by 25 years — by taxing high-income people more and expanding the Democrats&#x27; prescription drug negotiation program.Why it matters: It&#x27;s a sneak peek at his fiscal 2024 budget plan before the rest comes out Thursday. And like most presidential budgets, you should read it for the clues about his positioning rather than preparing for it to sail through Congress.

David Nather

Stories

Biden's tax-the-rich Medicare plan

Axios-Ipsos poll: Republicans call opioids No. 1 health threat

Two Americas Index: Must be fraud

Axios/Ipsos poll: Midterms warning for Democrats

Election denial: The offices that matter

Newsletter editions

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