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Axios Vitals

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Good morning … This has nothing to do with health care, but if you need a brief respite from the world's myriad horrors, do yourself a favor and turn on the sound while you watch this video of a TV crew trying to set up its live shot for the implosion of the Georgia Dome yesterday. Amazing.

​The ACA is the ultimate survivor

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The Affordable Care Act has survived more assassination attempts than Fidel Castro — and it's still kicking. The Kaiser Family Foundation's Larry Levitt has a piece in the JAMA Forum laying out the argument that the ACA "continues to escape death."

  • Levitt's piece is mostly focused on the Senate's repeal-and-replace efforts and the Trump administration's implementation decisions — cutting off payments for cost-sharing subsidies and dramatically scaling back enrollment outreach.
  • "If these efforts were intended to make the marketplace implode, they may, in fact, be backfiring," Levitt says, citing the weird abundance of plans with $0 monthly premiums and enrollment totals that are beating some experts' expectations.

This is just the latest chapter. The ACA has been a fixture of public debate since 2009, and it has never veered far from death's door. In that time, it has survived:

  • Any number of make-or-break moments during the legislative debate
  • Two potentially disastrous Supreme Court challenges
  • The Republican waves of 2010 and 2014, and the countless repeal votes that followed
  • A slew of self-inflicted wounds, from provisions that proved unworkable to the hot mess that was the HealthCare.gov launch.

Between the lines: The ACA has definitely taken some hits — it's not as strong its drafters might have hoped on the day it passed. But congressional Republicans' failure to repeal it, and President Trump backing into a massive increase in its subsidies, are just the latest signs of the law's surprising durability.

Until Congress repeals the individual mandate, anyway…

​Stopgap CHIP funds top $600 million so far

The federal government has paid out more than $600 million to 14 states and territories to make up for funding shortfalls in the Children's Health Insurance Program, according to the latest data from the Centers for Medicare & Medicaid Services. Federal CHIP funding expired at the end of September, and Congress isn't likely to get the money flowing again until the end of the year.

Why you'll hear about this again: Most states have enough leftover CHIP money to make it through the end of the year, and CMS is able to tap leftover funds from previous years to help states bridge the gap if they need it. But the number of states that need it is growing. CMS had shelled out just shy of $240 million in October. An additional $368 million in November brought the total to nearly $607 million so far.

  • The agency said in a recent memo to states that it had about $3 billion available for stopgap funding, including the payments it has already made.

What's next: Nevada, which isn't included in the totals here, has requested $11 million to keep its CHIP program afloat.

​Medicare takes a hatchet to lab payments

Axios' Bob Herman reported in September that Medicare was ready to slash payments to clinical labs by $670 million next year. Well, Medicare officially is moving ahead with the cuts, despite an outcry from the lab industry.

The details: Medicare basically is keeping the same payment reductions it proposed in September. The rates for 23 of the top 25 lab services by spending — including urine tests — will decrease by 10% next year, Bob reports.

What they're saying: Lab companies will continue to try to get lawmakers to delay the cuts, perhaps through the year-end spending bill. But Spencer Perlman of Veda Partners doesn't think that's a "slam dunk" because "Congress is so distracted by taxes and other issues, and because there is a cost to delaying implementation of [lab cuts] that requires offsets."

Why ambulances are so expensive

Yes, people really do take Uber to the emergency room. This is why: Taking an ambulance can leave you with thousands of dollars in unanticipated medical bills, as Kaiser Health News and the Washington Post explain:

  • Once upon a time, ambulances were part of the local fire department. Now, they're increasingly controlled by private-equity firms, and some charge by the mile.
  • Ambulances are often out of network, even if they take you to an in-network hospital.
  • Ambulance operators often don't join insurers' networks because the two parties don't agree on how much an ambulance ride is worth, according to KHN. If you use one, your insurer will often cover some part of the bill, then the ambulance company will send you a bill for the balance.

The last iron lungs

Gizmodo has a fascinating look at three patients who still use iron lungs — a technology that, admittedly, I did not realize was still around. They're all polio survivors, and all live in fear of their iron lungs breaking or needing repairs that no one will be able to perform quickly enough.

  • According to Gizmodo, Respironics, the company that ended up with responsibility for iron lungs through mergers with other companies, has been trying to switch patients to other devices.
  • The company told patients in 2004 that they could switch to newer products; stick with their iron lungs but acknowledge that repairs might be impossible; or take full ownership of their iron lungs.
  • "The 'yellow submarine' is my necessary, trusted, mechanical friend," one patient said. "I approach it with relief in store at night and thankfully leave it with relief in the morning."

The big picture: One thing the polio survivors had in common, per Gizmodo: "a desire for the next generations to know about them so we'll realize how fortunate we are to have vaccines."

What's on your radar? Let me know: baker@axios.com.