David Nather
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The Senate health bill is out. Here's your speed read

J. Scott Applewhite / AP

You can read it here, and a summary here. The highlights:

  • Ends the Affordable Care Act's mandates and most of its taxes.
  • Phases out its Medicaid expansion over three years, ending in 2024.
  • Limits Medicaid spending with per capita caps, or block grants for states that choose them. The spending growth rate would become stricter in 2025.
  • States could apply for waivers from many of the insurance regulations — though not protections for people with pre-existing conditions and coverage for young adults.
  • The ACA's tax credits would be kept in place, unlike the House bill — but their value would be reduced.
  • Funds the ACA's cost-sharing subsidies through 2019, but then repeals them.

Want more? Keep reading.

  • There's a stabilization fund to help states strengthen their individual health insurance markets.
    • $15 billion a year in 2018 and 2019, $10 billion a year in 2020 and 2021.
    • There's also a long-term state innovation fund, $62 billion over eight years, to help high-cost and low-income people buy health insurance.
  • The ACA tax credits continue in 2018 and 2019.
  • After that, they'd only be available for people with incomes up to 350 percent of the poverty line.
  • The "actuarial value" — the amount of the medical costs that insurance would have to cover — would be lowered to 58 percent, down from 70 percent for the ACA's benchmark plans. That's likely to reduce the value of the tax credits.
  • All ACA taxes would be repealed except for the "Cadillac tax" for generous plans, which would be delayed.
  • Medicaid spending growth rate under per capita caps would be same as House bill until 2025. Then it switches to the general inflation rate, which is lower than House bill.
  • States would be able to impose work requirements for people on Medicaid, except for the elderly, pregnant women and people with disabilities.
  • Children with complex medical needs would be exempt from the per capita caps.
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Cruz can't support health bill, but wants to make a deal

AP file photo

Sen. Ted Cruz says he hasn't given up on the Senate health care bill. He already released a statement with three other Republicans saying they're "not ready to vote for" the draft bill. But in a separate statement, Cruz says he wants to help make "real improvements" so it "provides the relief from Obamacare that Republicans have repeatedly promised the last seven years" — especially in reducing health insurance premiums.

What he wants: He'd give consumers "the freedom to choose among more affordable plans that are tailored for their individual healthcare needs." He also wants more flexibility for Medicaid, the ability to buy health insurance across state lines, expanded health savings accounts, and medical liability reform.

Between the lines: Cruz is hinting that he wants to be a dealmaker: "I want to get to yes, but this first draft doesn't get the job done." And Majority Leader Mitch McConnell's allies consider him an easier negotiating partner than the other conservatives, including Sens. Mike Lee and Rand Paul. The catch is that even though most of his ideas have broad support among Republicans, not all of it can be done under Senate budget rules.

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Senate health bill faces conservative rebellion

AP file photo

Four Senate Republicans — Ted Cruz, Mike Lee, Rand Paul, and Ron Johnson — just released a statement saying they're "not ready to vote for" the Senate health care bill. That's enough to kill the bill if they actually vote against it. "It does not appear this draft as written will accomplish the most important promise that we made to Americans: to repeal Obamacare and lower their healthcare costs," they wrote.

The bottom line: If a rebellion happens, it's largely because conservatives want to get rid of more of the Affordable Care Act's insurance regulations. And that's a big part of the Republican dilemma. Conservative Republicans say those rules make individual health insurance more expensive, and they're right — but the most expensive regulations are the ones that protect people with pre-existing conditions, which is exactly what Senate Republicans don't want to get rid of.

Deeper dive: The draft Senate bill would let states escape some of the ACA's "Title I" insurance regulations, like minimum benefit requirements — but not the pre-existing condition protections, like requiring insurers to cover sick people and preventing them from charging those consumers higher rates. According to an analysis circulated by Sen. Bill Cassidy, prepared by the consulting firm Oliver Wyman, that's what added the most to individual insurance costs.

Here's what Cruz said earlier this week: "There is no doubt there has got to be significant reform to reduce the burdens from the Title I insurance mandates. Why? Because they're one of the principal drivers of premiums skyrocketing."

For context: Sen. Rand Paul said today that it's more than just the regulations — it's also the fact that the Senate bill keeps the ACA subsidies in a scaled-back form: "It doesn't fix the death spiral in Obamacare, it simply subsidizes it with taxpayer money to insurance companies."

What the House bill does: It allows states to waive the pricing rules for sick people under certain conditions. The Senate bill doesn't go that far.

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Vitals

Good morning ... Today's the day — We can't wait to read the Senate health care bill. In the meantime, if you're visiting the Capitol, and you see hordes of reporters coming at you as we interview some senator, find somewhere to hide. Apologies in advance.

And we have one more newsletter joining the Axios family! It's Media Trends, by our colleague Sara Fischer, and it's about the changes in different kinds of media that affect our lives — from cord-cutting to consolidation to fake news. It starts next week. Sign up here.

Senate Republicans are about to find out what's in their bill

Lazaro Gamio / Axios

It's not just the rest of us who are in suspense. When Senate GOP leaders post the draft bill online this morning, it will be the first look at the details for a lot of rank and file Senate Republicans, too — aside from the leaks, of course.

  • "How can I discuss it when I don't know what it is?" —Sen. John McCain
  • "Believe me, I'm even more eager than you are to see the bill." — Sen. Susan Collins

Reality check: It's not a total mystery — Caitlin Owens has as good a read as anyone, and we're getting new details this morning from sources who have been briefed. And the bottom line is, it's not going to be radically different than what the House passed. It still gets rid of as many Affordable Care Act insurance rules as it can, rewrites the subsidies, and puts a tight squeeze on Medicaid spending.

The highlights of what we're likely to see:

  • Subsidies would still be available to help people buy health insurance, but only up to 350% of the federal poverty level starting in 2020, not the ACA's 400%.
  • It will have a four-year reinsurance program to help state insurance markets — though it might have to be passed separately, in the reauthorization of CHIP.
  • The ACA's cost-sharing reduction subsidies — one of the main things insurers say they need — would be funded through 2019. That may get challenged on the Senate floor, though.
  • States would get to waive some of the ACA's insurance regulations, through a beefed-up version of the law's "Section 1332" waivers.
  • Medicaid expansion will be phased out more slowly than in the House bill, ending the expansion in 2024.
  • But Medicaid will still have per-capita caps — and with tighter spending limits than the House bill starting in 2025.

Looking ahead: Democrats (and Republicans) will have a "virtually unlimited opportunity to amend it during the budget process on the floor" next week, per Senate HELP Committee chairman Lamar Alexander. So at least you can look forward to that.

What to look for in the Senate bill

We're getting a better idea of what's in the bill, but a huge number of policy details still have the potential to significantly alter the way it would affect real-world insurance markets — which means there are also a lot of political landmines for GOP leaders to avoid.

Here are a few big things we'll be looking for once the actual bill drops:

  • Subsidy specifics: We know the bill will tie its premium subsidies to income more closely than the House did — a strong indication that Senate leaders are looking for something less "mean," in the president's words, than the House bill. But everything in health care has winners and losers: The exact structure of the bill's subsidies will determine who the losers here would be.
  • The Medicaid balance: We're expecting moderates to get their way on a more gradual phaseout of the Medicaid expansion, but conservatives to get their way on the funding levels for new capped Medicaid payments. Will more moderate GOP senators accept that compromise?
  • Broadly, how much work is left to do? McConnell is calling this a "discussion draft," but the vote is still supposed to happen next week. Does the bill already include, for example, a dedicated fund to combat the opioid crisis, or some sort of accommodation for Alaska's unique insurance market? Are all its funding levels filled in — and final? On an already compressed timeline, how much negotiating will happen at the 11th hour?

The meltdown didn't happen — now keep your eyes on September

There was no nightmare scenario yesterday — no ACA marketplace meltdown. Health insurers across the country submitted preliminary rate filings yesterday to sell ACA plans on HealthCare.gov, and many companies stayed in their existing markets, as Bob Herman reported.

There were some notable defections — like Anthem's exit from Indiana (its home state) and Wisconsin. Those two states lost two smaller ACA carriers as well.

What's next: Waiting for the premium increases to be made public, either by states or through the federal rate review website. And now, there are new important dates to watch:

  • August 16: Deadline for companies to make any changes to their ACA plans.
  • September 27: Deadline for states to give notice of final insurer participation.

The bottom line: David Anderson, a health policy researcher at Duke University who used to work at a health insurance company, put the process to Bob this way: "[Yesterday] the plans and states swiped right for each other. August is dinner with the parents. And September is down on a knee."

Medicare's next chapter takes shape

Bob waded through a 1,000-page proposed rule tied to the Medicare and CHIP Reauthorization Act — which is the next iteration of Medicare paying doctors for quality care — so you don't have to. You can read the entire tome here, if you want to.

In the meantime, a couple highlights:

  • More doctors will be exempt from participation in the baseline incentive program (read page 721 of the document). HHS secretary Tom Price heeded the calls of his fellow doctors who either don't like regulations or want to move slowly into the payment system.
  • Doctors won't be penalized for having older electronic health records. Another win for doctors, but a small downer for big health tech companies like Cerner, Epic, and Athenahealth, which wanted a mandate for their medical record and billing systems.

How FDA hopes to clear a path for generic drugs

OK, FDA fans, mark your calendars for July 18. That's when the agency is holding a public hearing to get suggestions on how to promote more competition from generic drugs — one of FDA commissioner Scott Gottlieb's main solutions to rising drug prices. In a blog post yesterday, Gottlieb said the goal is to find out if the agency's rules "are being used in ways that may create obstacles to generic access, instead of ensuring the vigorous competition Congress intended."

Between the lines: His post suggests he's especially interested in finding ways to keep the makers of brand-name drugs from blocking generic drug companies from getting samples of their products — an issue Collins raised with him at a Senate subcommittee hearing earlier this week. The key quote: "We are actively looking at ways our rules are being used and, in some cases, misused."

What we're watching today: Come on.

What we're watching this week: Congressional Budget Office score, maybe tomorrow but more likely Monday. President Trump signs the VA Accountability Act into law Friday. Also, the Biotechnology Innovation Organization's annual convention in San Diego ends today, and Mylan's annual shareholder meeting is today too, because why not?

Send coffee to the Senate Press Gallery and tips to david@axios.com / baker@axios.com.

Featured

Senate Republicans are about to find out what's in their bill

Lazaro Gamio / Axios

It's not just the rest of us who are in suspense. When Senate GOP leaders post the draft bill online this morning, it will be the first look at the details for a lot of rank and file Senate Republicans, too — aside from the leaks, of course.

Reality check: It's not a total mystery — Caitlin Owens has as good a read as anyone, and we're getting new details this morning from sources who have been briefed. And the bottom line is, it's not going to be a totally different than the House passed. It's going to be mostly the same structure, with changes at the margins.

"How can I discuss it when I don't know what it is?" Sen. John McCain asked after one last round of meetings yesterday afternoon. Sen. Susan Collins, a crucial swing vote, said she didn't know basic details about its rewrite of Medicaid, like how slowly it would phase out Medicaid expansion and how strict its spending limits would be. "Believe me, I'm even more eager than you are to see the bill," she told reporters.

The highlights of what we're likely to see:

  • Subsidies would still be available to help people buy health insurance, but only up to 350% of the federal poverty level starting in 2020, not the ACA's 400%.
  • It will have a four-year reinsurance program to help state insurance markets — though it might have to be passed separately, in the reauthorization of CHIP.
  • The ACA's cost-sharing reduction subsidies — one of the main things insurers say they need — would be funded through 2019. That may get challenged on the Senate floor, though.
  • States would get to waive some of the ACA's insurance regulations, through a beefed-up version of the law's "Section 1332" waivers. Pre-existing condition protections and coverage for young adults up to age 26 couldn't be waived.
  • Older customers could be charged five times as young adults, compared to three times as much under the ACA.
  • Medicaid expansion will be phased out more slowly than in the House bill, ending the expansion in 2024.
  • But Medicaid will still have per-capita caps — and with tighter spending limits than the House bill starting in 2025.
  • All ACA taxes would be repealed, except for the "Cadillac tax" on generous health insurance plans. That would just be delayed, as in the House bill.

Looking ahead: Democrats (and Republicans) will have a "virtually unlimited opportunity to amend it during the budget process on the floor" next week, per Senate HELP Committee chairman Lamar Alexander. So at least you can look forward to that.

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White House launches ACA repeal website

White House

The White House is giving a push to the Senate health care bill with a new website highlighting the Trump administration's arguments for repealing the Affordable Care Act. It features a video outlining the problems it sees with the law — skyrocketing individual insurance premiums, insurers leaving the marketplaces — and statistics about the lack of competition and people who have paid penalties rather than buying health coverage.

The goal: "This page will highlight the complete disaster that has been Obamacare, and feature videos and personal stories of everyday Americans across the country who have been negatively impacted by its failure," per a White House official. It will be updated with highlights of the Senate's replacement plan after the bill is released tomorrow.

Why it matters: It's all part of the administration's efforts to build momentum for the repeal effort ahead of the Senate vote next week, and it could give a nudge to Senate Republicans who are reluctant to vote for the bill. President Trump will keep talking about the ACA's problems in critical states — he's likely to bring it up in Iowa today — and HHS Secretary Tom Price is tweeting videos with doctors and patients talking about the law's problems.

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Why a cutoff of insurer payments could hurt the middle class

AP

The New York Times makes an important point about what would happen if the Trump administration stops paying for the Affordable Care Act's cost-sharing reduction subsidies: It hurts the middle class more than low-income customers. Here's why:

  • The subsidies are meant for low-income people. Even if insurers stop getting reimbursed for them, they still have to pay them.
  • But insurers say they'll raise their premiums to make up for the losses. That wouldn't hurt low-income customers, because they also get tax credits that would cover much of the higher premiums.
  • But middle-class customers — who earn too much to qualify for those tax credits — would have to pay the higher premiums without any financial help.

Where it stands: The Trump administration made the June payments, but hasn't made any promises beyond that. And Congress is still debating whether to fund them.

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Vitals

Good morning ... Looks like we might see the draft Senate health care bill tomorrow! You know what we would do if we had a countdown clock? We wouldn't use it. That's what CNN is for.

Even the Senate doesn't seem excited about its bill

David Nather / Axios

There's certainly a lot of mystery and suspense about the Senate health care bill, as you can see. (That's Republican Conference chairman John Thune, the tallest Senate GOP leader.) There's just not a lot of excitement in the air. They're on track to release what Majority Leader Mitch McConnell calls a "discussion draft" of the bill on Thursday, but we have yet to hear anyone — including McConnell — say, "We're going to be so pumped when we pass this."

The latest from the Senate:

  • The bill we see on Thursday probably isn't the one the Senate will vote on next week, as Caitlin Owens reported yesterday. That's because they're going to include state waivers from several Affordable Care Act insurance regulations, but with the full knowledge that they could get stripped out.
  • Senators Ted Cruz, Mike Lee, and Ron Johnson all made it clear they're not on board.
  • "We need to do a substantially better job of driving down the cost of premiums," Cruz told reporters. What he wants: more freedom from the ACA's insurance regulations and "far more robust flexibility" in Medicaid.
  • Moderate Republicans didn't sound happy with the plan to limit Medicaid spending and slow the growth rate in 2025. "I don't look favorably on it, that's for sure," Sen. Shelley Moore Capito told Caitlin yesterday. "Not for it," Sen. Rob Portman said.
  • Sen. Bob Corker wasn't thrilled with the secrecy of the process: "I'm one of those folks that thinks the public process is useful, and I've said that from the beginning. That's not the process that's been pursued."
  • Oh, and President Trump is at it again. Our colleague David McCabe reports that he told tech CEOs on Monday that he had urged Senate Republicans to put "more heart" into their bill.

The bottom line: This is far as McConnell would go, when asked if he was confident the bill will pass: "We're going to make every effort to pass a bill that dramatically changes the current health care law."

For context: Senate Democrats didn't have the votes in hand when they took the ACA to the floor in December 2009, either. And the bill they voted on was different from the one they introduced: They dropped the "public option." Still, they released their bill way more than a week before the vote.

Impact of "Lossoff"

Even a Jon Ossoff victory last night, in the race to fill HHS secretary Tom Price's old House seat in Georgia, might not have slowed down the repeal-and-replace train. His loss definitely won't.

Sure, it's a deeply Republican district in which Ossoff, the Democrat, did better than you'd expect a Democrat to do. But when it comes to health care, Democrats needed a win — and not a symbolic one. If you're a vulnerable Republican wondering how to approach this bill, Tuesday's results gave you no reason to be any more concerned than you already were.

The great Medicaid divide

Data: Kaiser Family Foundation Health Tracking Poll, May 16-22, 2017; Chart: Andrew Witherspoon / Axios

One big factor in the Republicans' Medicaid policies, Kaiser Family Foundation's Drew Altman points out in today's column, is that many of them see Medicaid in a different way than the rest of the public:

More than half of Republicans in the latest Kaiser tracking poll said they view Medicaid as a welfare program, similar to other social programs like food stamps. By contrast, majorities of Democrats and independents — and a majority of the overall public — see it as more similar to other health insurance programs.

Why it matters: Anyone who sees Medicaid as a welfare program is likely to be more open to cuts — and tough new rules like work requirements — than people who see it as health insurance for vulnerable people.

One bit of good news for the ACA marketplaces

It's filing deadline day for health insurers, and Oscar, the health insurance startup in New York, announced this morning that it's filing to sell insurance in Ohio, New Jersey, Texas, Tennessee, and California as well. In a blog post, CEO Mario Schlosser says he's confident that the market will stabilize for 2018: "For all of the political noise, there are simply too many lives at stake for representatives in Washington, D.C. not to do what's right for the people."

Check the Axios health care news stream throughout the day for news on other insurers.

Drug companies are going to love Trump's plan for drug pricing

As we expected, Trump's plan to tackle drug pricing is a plan the pharmaceutical industry can get behind. The New York Times reports that Trump's pending executive order will tread relatively lightly — it's heavy on ordering agencies to study their options or roll back regulations, and its most aggressive steps are mostly industry-approved. Those would include value-based purchasing and changes to the drug-discount program known as 340B — changes that some experts believe could actually raise drug prices.

Gottlieb's orphan drug "SWAT team"

FDA commissioner Scott Gottlieb says he's committed to getting rid of the agency's backlog of requests for "orphan drug" classification, which gives special benefits to the makers of those drugs. And he has a new idea for how to do it. In testimony before a Senate Appropriations subcommittee yesterday, Gottlieb said he's setting up an orphan drug "SWAT team" — a group of FDA officials that will be asked to "completely eliminate" the backlog within 90 days.

The bottom line: It's part of a broader "medical innovation development plan" Gottlieb says he'll be rolling out in the coming months. "Orphan drug" classifications are important because they mean the FDA considers the drugs to be aimed at rare diseases, and the drug makers get incentives — like tax credits for clinical testing — to encourage their work.

Billion-dollar Medicaid contracts quietly chug along

ICYMI, Mississippi quietly awarded new Medicaid contracts to three companies: new entrant Molina plus Centene and UnitedHealthcare, both of which already ran the state's Medicaid program. The contracts go into effect July 2018 and are worth a hefty chunk of change: about $2.8 billion per year.

Why it matters: The federal government and states spent $236 billion in 2016 on Medicaid managed care — in which states make monthly per-capita payments to insurance companies. That number is expected increase as more states switch to or expand their Medicaid managed care programs. But these deals largely fly under the radar because they are complex and aren't advertised by states.

Mark your calendars: A handful of states will award billions of dollars in new Medicaid contracts soon, and the contracts would be affected heavily by any funding cuts Republicans impose.

  • This summer: Illinois, 2.7 million people
  • October: Ohio,130,000 people who need expensive long-term care
  • March 2018: Arizona, 1.6 million people
  • March 2018: New Mexico, 700,000 people
  • September 2018: North Carolina, 1.5 million people

States' patchwork rules on unexpected medical bills

Data: Commonwealth Fund; Chart: Chris Canipe / Axios

Consumers in most of the country don't have much protection against the practice known as "balance billing" — which happens when patients use an out-of-network provider, then receive a bill for however much of that provider's fee their insurance didn't cover. As health researchers at Georgetown University explain in a new analysis, balance billing is an issue in emergencies — for example, being rushed to the emergency room at an out-of-network hospital, or even being treated by an out-of-network doctor at an in-network facility.

Federal law permits balance billing, as do most states, according to Georgetown's research. And it's a sensitive issue now because so many ACA plans offer relatively narrow provider networks as a way to keep premiums down. Don't expect that to change under the GOP health care bill, either.

What we're watching today: The deadline for insurers to file their rates in their 39 states whose exchanges rely on HealthCare.gov. There's supposed to be a Senate Appropriations subcommittee hearing on the VA budget at 2:30 p.m. Eastern, but it's likely to get shut down because Democrats are refusing to allow hearings to proceed. It's one of their protest tactics against the health care bill.

What we're watching this week: The Senate, mostly. Also the Biotechnology Innovation Organization's annual convention in San Diego, through Thursday, and Mylan's annual shareholder meeting, Thursday.

How's our driving? Send your tips, feedback, questions and concerns to david@axios.com and baker@axios.com.

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Even the Senate doesn't seem excited about its health bill

J. Scott Applewhite / AP

There's certainly a lot of mystery and suspense about the Senate health care bill. There's just not a lot of excitement in the air. They're on track to release what Majority Leader Mitch McConnell calls a "discussion draft" of the bill on Thursday, but we have yet to hear anyone — including McConnell — say, "We're going to be so pumped when we pass this."

For context: Senate Democrats didn't have the votes in hand when they took the Affordable Care Act to the floor in December 2009, either. And the bill they voted on was different from the one they introduced: They dropped the "public option." Still, they released their bill way more than a week before the vote.

The latest from the Senate:

  • The bill we see on Thursday probably isn't the one the Senate will vote on next week, as Caitlin Owens reported yesterday. That's because they're going to include state waivers from several Affordable Care Act insurance regulations, including minimum benefits — but with the full knowledge that they could get stripped out if the parliamentarian says they violate Senate budget rules.
  • Ted Cruz, Mike Lee, and Ron Johnson all made it clear they're not on board.
  • "We need to do a substantially better job of driving down the cost of premiums," Cruz told reporters. What he wants: more freedom from the ACA's insurance regulations and "far more robust flexibility" in Medicaid.
  • Moderate Republicans didn't sound happy with the plan to limit Medicaid spending and slow the growth rate in 2025. "I don't look favorably on it, that's for sure," Sen. Shelley Moore Capito told Caitlin yesterday. "Not for it," Sen. Rob Portman said.
  • Sen. Bob Corker wasn't thrilled with the secrecy of the process: "I'm one of those folks that thinks the public process is useful, and I've said that from the beginning. That's not the process that's been pursued."
  • Oh, and President Trump is at it again. Our colleague David McCabe reports that he told tech CEOs on Monday that he had urged Senate Republicans to put "more heart" into their bill. (It seemed to be a continuation of his reported comments where he called the House bill "mean.")

The bottom line: This is far as McConnell would go, when asked if he was confident the bill will pass: "We're going to make every effort to pass a bill that dramatically changes the current health care law."

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Vitals

Good morning ... The Senate is barreling toward a big, party-line health care vote, even as a special election for a once-safe seat has turned into a referendum on that health care plan. Welcome to the latest and decidedly least fun "Back to the Future" sequel.

The Senate is (still) planning to vote next week

Giphy

Details about what's in the Senate bill are slowly starting to leak out, along with details about the process. Yes, Majority Leader Mitch McConnell still plans to hold a vote before the July 4th recess, which means things are about to start happening extremely quickly.

Timeline: We learned last night that GOP senators (or at least some of them) are being advised that they'll get a summary, legislative text, and preliminary score of the bill before they leave town Thursday evening. Thursday's lunch could get very nitty-gritty on policy details, one aide said. But it's also important to note that in a process as chaotic as this, plans can change quickly.

As the Wall Street Journal reported last night, a Congressional Budget Office score is expected early next week.

Medicaid portion: Here's what Caitlin Owens has heard about this part of the bill:

  • It would keep the growth rate for Medicaid per-person funding caps that is in the House bill, but only until 2025. The growth rate would then be reduced — from a metric pegged to medical inflation to one pegged to regular old inflation.
  • The Medicaid expansion would have a three-year glide path down to a state's traditional funding level (as opposed to the higher Affordable Care Act match rate) beginning in 2020. This is somewhat of a win for moderates compared to the House bill, although they'd been pushing for a seven-year transition.
  • States would be able to pick the base spending amount for their starting growth rate based on eight consecutive quarters. This would likely allow states to choose a higher base spending amount.

Is Jon Ossoff the new Scott Brown?

A special election...in the middle of a big and controversial health care overhaul...for a seat no one ever thought would be competitive...which was last held by a major player in health care politics — haven't we seen this movie before?

If Democratic contender Jon Ossoff manages to squeeze out a victory tonight in Georgia's sixth congressional district, it'll be hard to deny some thematic similarities to Scott Brown's upset election in 2010. The two aren't identical, of course: Brown denied Democrats a 60th vote in the Senate; Republicans can easily afford to lose one House seat and still pass a bill.

But as canaries in coal mines go, the similarities could be telling. Brown's victory was all about the ACA, and Ossoff has made health care an integral part of his closing argument in the race for HHS secretary Tom Price's former seat.

Yes, but: Before Democrats start getting too excited about this analogy, though, remember: You all still passed your bill after Brown won — and held your Senate majority for another three years.

How states treat sexual assault and pre-existing conditions

Data: FiscalNote research; Chart: Andrew Witherspoon / Axios

An early wave of stories inaccurately suggested the House GOP health care bill would allow rape and sexual assault to be treated as pre-existing conditions. Those stories have been thoroughly debunked. Even with the House bill's state waivers, most states, we were told, have their own laws preventing sexual assault from being treated as a pre-existing condition.

State laws: Turns out that many of those laws are so vague that they probably wouldn't settle the issue. This map is based on an analysis from FiscalNote, a government relationship management software company. It found that 29 states have vague laws that only protect "victims of domestic violence," without any definition that includes sexual assault. That only matters in states that get state waivers, and only under certain conditions, but it's worth knowing. More here.

Lobbying for a children's Medicaid carveout

The Medicaid spending limits in the GOP health care bills are already forcing advocacy groups to ask for special protections. For example, the Children's Hospital Association sent out a June 15 memo saying it would try to get kids exempted from the Medicaid cuts if it couldn't stop the bill outright.

Key quote: "Our straightforward ask is to exempt children in Medicaid from the per capita caps and block grants," the group stated in the memo obtained by Vitals. "If we have priorities within this ask, we should at least exempt the disabled and medically complex children."

Why it matters: It's easy to see how the Medicaid spending limits could lead to a competition between vulnerable groups, or at least tension if one group gets a carveout and the others don't. But Jim Kaufman, the group's VP of public policy, isn't trying to compete with other groups. He says he just wants to draw attention to the damage that spending limits could do to the 30 million children on Medicaid. "This is a bad bill for kids," he told us.

What they found: When Kaufman went to Capitol Hill to talk to House Republicans before their vote, he said, some didn't know that Medicaid covered 30 million children: "They would say, 'Oh, no, all of the kids are in CHIP.' "

​Good news for ACA markets, sort of

Monday was a day of very mixed news for the ACA marketplaces, but at least no insurers pulled out. The highlights:

  • Medica, the last insurer standing in Iowa, announced it would stay in the marketplace after all — but it says it needs an average rate increase of 43%, the Des Moines Register reports.
  • Anthem, which had been noncommittal about selling ACA plans next year, said it will stay in Missouri for now — but warned that it could change any part of that decision at any time, per the St. Louis Post-Dispatch.
  • Premera will sell health plans in one of the two counties in Washington state that was in danger of having no insurance options.

​Higher premiums and fewer options

That's what the consulting firm Avalere Health expects to see in the exchanges next year, based on its review of eight states' early rate filings. Avalere's findings:

  • Premiums for "silver" plans (the middle-of-the-road option, and the most popular type of plan) are rising 18% next year, after a 12% increase this year.
  • 41% of counties could have only one insurer, up from 33% this year.
  • Insurers will likely keep moving into and out of certain markets through the summer, as the political situation around the exchanges becomes clearer.

Aetna embraces medication to combat opioid crisis

Aetna is going all in on medication-assisted treatment in response to the opioid epidemic, according to a letter CEO Mark Bertolini is sending today to a handful of Democratic senators. Bertolini highlights three goals the insurer hopes to achieve by 2022:

  • Reduce inappropriate opioid prescriptions by 50%.
  • Increase by 50% the number of opioid addicts treated with medication-assisted treatment and other evidence-based treatments.
  • Increase the number of enrollees with chronic pain who use alternative pain treatments by 50%.

Go deeper: Aetna's embrace of medication-assisted treatment is a sharp contrast from some insurers' previous reluctance to cover the approach, which Bob Herman covered for Modern Healthcare. It also follows Tom Price's controversial comment saying medication-assisted treatment is "substituting one opioid for another."

But Aetna has already worked to make medication more available: Earlier this year, it removed all pre-authorization requirements for certain products and put them on a preventive medicine list that reduces cost-sharing for patients.

What we're watching today: Did we mention the Georgia congressional special election is today? Also, the Senate Appropriations agriculture subcommittee holds a hearing on the FDA budget, 10:30 a.m. Eastern (unless Senate Democrats shut it down with their procedural protests). Livestream here.

What we're watching this week: The insurer filing deadline to provide ACA marketplace coverage, Wednesday. Also, Biotechnology Innovation Organization annual convention in San Diego, today through Thursday. Senate Appropriations subcommittee hearings on the VA budget, Wednesday, and the NIH budget, Thursday. Mylan annual shareholder meeting, Thursday.

Let us know what else you're watching: david@axios.com, baker@axios.com.