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Axios Vitals


Good morning...Today's the big day! Maybe. The House was supposed to vote on Trumpcare, as soon as Republican leaders think they have the votes, and before they lose any more. But first, they might rewrite a huge portion of the bill to get rid of some major Obamacare insurance regulations.

Will it be enough? Or will they have to pull the bill? We're still going with "they'll squeeze it out at the last minute" — but even the most seasoned House observers aren't sure. With the Koch brothers against it on one side, and Republican moderates pulling away on the other, we've got actual suspense, not fake suspense.

It's time for the House to vote on Trumpcare — or is it?

Greg Ruben / Axios

Looks like the White House and GOP leaders are willing to meet some of the conservatives' demands to knock out Obamacare's insurance regulations — even though there's no guarantee those changes would comply with the budget rules, and they could just get stripped out in the Senate. So why go through the exercise? Because President Trump and House Speaker Paul Ryan need their votes, and right now, the goal is just to get something through the House.

Here's where things stand as of this morning:

  • Top Republicans may be willing to strip out Obamacare's "essential health benefit" requirements to win the votes of the Freedom Caucus.
  • These are the 10 categories of benefits that have to be covered under the law: outpatient care, emergency services, hospitalization, maternity care, mental health, prescription drugs, rehab, laboratory services, preventive care, and pediatric services.
  • Still up in the air is whether the GOP will also be willing to strip out Obamacare's other insurance regulations — like requiring insurers to cover pre-existing conditions and preventing them from charging sick people more than others.
  • The Freedom Caucus wants them out because they think those are the reasons individual health insurance became so expensive under Obamacare — but the law's supporters say those health plans used to be skimpy and will go back to being skimpy if the benefits aren't required.
  • The change of plans happened after the White House offered to try to get those regulations stripped out in the Senate, if the conservatives would vote for the House bill as is. The conservatives rejected that offer because they don't trust the Senate.
  • The risk, as Democratic aides warned, is that the Senate could just strip out all the insurance changes.
  • The fallout: one of the leading moderates — Rep. Charlie Dent — announced last night that he's a "no," due to the likely coverage losses and high health insurance costs for low-income people.
  • As of this morning, there is no Congressional Budget Office estimate for the latest changes.
  • There's also no rule for the floor debate. The House Rules Committee recessed late last night without approving one. They did give themselves the ability to write a same-day rule.
  • In the meantime, the Koch brothers are doing their best to pull conservatives away from the GOP bill: They're setting up a "seven-figure fund" to support any lawmakers who vote against it.

This pretty much sums up how yesterday went

It's not that Republican leaders lost Rep. Thomas Massie's vote — he was already against the bill, from the conservative side. It's just that he's now even farther away from a "yes." He told Glenn Beck that he was upset by a report that one of the latest changes to the bill would make millions of veterans ineligible for the tax credit. (Republicans tell me that's not true — they're already eligible through regulations, but the GOP just can't write it into law without violating budget rules.)

It's not like the House Obamacare vote was easy, either

Sure, it's suspenseful when the House doesn't have the votes for a big health care bill. But it's easy to forget that, at this point in the passage of the Affordable Care Act, then-Speaker Nancy Pelosi didn't have the votes, either.

On the day before the House vote on the original bill, she was trying to win the support of anti-abortion Democrats, led by then-Rep. Bart Stupak, without losing the support of the many Democrats who supported abortion rights — and the powerful abortion rights groups. It was a different fight than House Speaker Paul Ryan trying to get conservatives and moderates on board now, but it wasn't an easy balance for Pelosi, either. The final tally, on Nov. 7, 2009: 220-215.

The lesson: This could all still fall apart today — but don't underestimate what can happen when a goal is important enough to the majority party.

The biggest losers: the poorest third of families

Lazaro Gamio / Axios

A lot of health care wonks were talking yesterday about an Urban Institute analysis that found the GOP health care bill would be regressive, leaving high-income families better off and low-income families worse off. So Caitlin Owens and Lazaro Gamio, our visuals editor, took the analysis one step further: They compared Urban's data to Current Population Survey data to figure out how many people would be hit by those changes.

The result: The poorest third of families would be worse off, middle-income families would be slightly better off, and those making more than $200,000 a year — about 8 percent of families — would benefit the most. Read the story here.

Your Trumpcare reading guide for the House vote

Quick reads to help you before today's vote (while you're sitting through all the boring opening speeches):

  • Re-upping this piece by Jeanne Lambrew, a former health care adviser to President Barack Obama, explaining why essential health benefits are in the law.
  • On the other side of the debate, this American Enterprise Institute piece argues that the required benefits discouraged young adults from buying coverage because they "refused to buy more insurance than they wanted or needed."
  • The American Academy of Actuaries says the "continuous coverage" requirement — which would charge a penalty for people who don't keep themselves insured — "would likely not be strong enough to avoid lower enrollment and a deterioration of the risk pool."
  • The Brookings Institution estimates that the changes to the bill won't reduce the coverage losses, and they could be "somewhat higher" thanks to the new options for Medicaid block grants and work requirements.
  • On the bright side for conservatives, the Committee for a Responsible Federal Budget concludes that the bill could save $2 trillion over two decades.

Health care sees dollar signs in surgery centers

Odds are if you've had elbow or wrist surgery lately, it was done in an ambulatory surgery center. The outpatient facilities are where physicians perform routine procedures and get patients back home in less than a day. Bob Herman reports there's quietly been a lot of consolidation among surgery center chains.

Why there's been a buying spree: More care is being done in the outpatient setting since it's less expensive than getting the same care inside a hospital. Yet, surgery centers are very profitable because they try to schedule as many quick, elective surgeries as possible, mostly for people who have better-paying commercial health insurance.

Expect more activity: There are 5,500 ambulatory surgery centers in the United States. Financial analysts with Barclays estimate half are not owned by a chain, leaving "ample room" for deals. For more details on the consolidations, read Bob's story here.

Oh yeah, a couple of Phase 3 bills passed

Here's what the House did yesterday on two of the health care bills that aren't going anywhere in the Senate:

  • Eliminating the antitrust protection for insurance providers: Passed 416-7
  • Association health plans: Passed 236-175
The difference: The antitrust bill didn't draw any opposition, but that could be because it wouldn't really do anything to health insurance premiums, according to the Congressional Budget Office. The association health plans bill, however, was more controversial because those health plans would operate under different rules than all the others — resulting in "cherry-picking, adverse selection, and increased costs for sicker individuals," according to the American Academy of Actuaries.

What we're watching today: The sweat on Paul Ryan's face. Also, Trump meets with the Freedom Caucus, 11:30 a.m. Eastern.

What we're watching next week: The sweat on Mitch McConnell's face.

Thanks for reading, and lemme know if you have any Trumpcare metaphors that haven't been beaten to death: