David Nather
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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.
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Rules Committee update: You haven't missed a thing

More than three hours later, the House Rules Committee still hasn't gotten around to taking up any actual amendments that House members want to add to the GOP Obamacare repeal bill before it goes to the floor tomorrow. They've spent the whole time arguing about whether the GOP bill is being rushed, whether Obamacare was rushed, and whether the Republicans' "continuous coverage" rule — penalizing people who don't stay insured — is an adequate substitute for Obamacare's individual mandate.

Oh, and Rep. Alcee Hastings did quote Janis Joplin. The response from Rules Committee chairman Pete Sessions: "I promise not to talk about ZZ Top."

They've recessed for House votes, and have yet to take up any of the more than 20 proposed amendments they're supposed to consider. On the bright side, one House GOP aide tells me the meeting probably won't last all night: "All dayer, maybe. Not all nighter."

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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: david@axios.com.

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Report: change in House GOP tax credits could make 7 million veterans ineligible

AP file photo

Chris Jacobs, a conservative health care analyst, discovered that a "technical change" to the tax credits could cut out veterans who are eligible for Veterans Administration health care but not enrolled in it. According to Jacobs, as many as 7 million veterans could be ineligible for the tax credit under the new language.

The House Rules Committee is meeting now, so it would have been easy for them to just introduce another technical amendment to rewrite the language. But the big question, Jacobs writes, is: "What other changes, tweaks, errors, or other unintended consequences might such rushed legislation contain?"

Update: Republicans say veterans wouldn't actually be shut out of the tax credit. They're eligible now through a regulation, but House Republicans wanted to write that into law. The Senate said no, because that could violate the rules of the budget "reconciliation" procedure they're using. So House Republicans took the language out, and will try to pass it separately. Meantime, the regulation is still in place.

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Vitals

Good morning...Trumpcare goes to the House Rules Committee today to get ready for the big floor vote, which will be agonizing for Republicans because many of them don't really have a good choice. It's pretty clear that GOP leaders don't have the votes at the moment, but remember that it's the House and it wouldn't be the first time the votes came together at the last minute. Keep your eye on that House floor tomorrow night.

Trumpcare staggers toward its big day

Greg Ruben / Axios

It's almost time for Trumpcare to go to the floor! But first, who's ready for another really long day in a committee hearing room? That's great, because the Rules Committee is ready to spend many hours talking about amendments that will never get a vote. Unless they decide to give the Freedom Caucus one floor vote to make them happy.

Here's what to watch today:

  • The Rules Committee meets at 10 a.m. to plow through more than 20 amendments, most of which will never go to the House floor. But there's one substitute by Freedom Caucus member Mo Brooks that would completely repeal Obamacare, so watch to see if he gets a vote. Same with Rep. Joe Barton's amendment to end Medicaid expansion faster.
  • Health and Human Services secretary Tom Price is signaling to his former House colleagues that the administration is done negotiating on amendments. "At some point, you've got to put down the pens, and the hour is late," he said yesterday on the Hugh Hewitt show.
  • President Trump is sure to keep working on Republicans himself, following his visit to Capitol Hill yesterday and a meeting with moderate Republicans at the White House.
  • Trump has made progress in winning over moderates, and some conservatives are dropping their opposition because of the latest changes to the bill — including Rep. Gary Palmer of Alabama, who voted against the bill in the House Budget Committee but now supports it.
  • There are still a lot of holdouts, even after the Trump visit. Republicans can only lose 21 votes, and multiple reports suggested they're currently losing more than that. (The New York Times reports they could be short by as many as three dozen votes.)
  • From a leadership source late yesterday: "We are moving members. Going in the right direction. Still working."
  • Two powerful conservative groups — Heritage Action and Americans for Prosperity — oppose the bill and are making this a "key vote," meaning they'll keep track of any Republicans who vote for it. (The National Right to Life Committee, however, is supporting it.)
Oh, and don't forget the Senate, where they can't lose more than two Republicans. So here's three who are opposing it: Sens. Susan Collins, Rand Paul, and now Mike Lee, who tweeted yesterday that "I am a no." Wait your turn, Senate. Stop stealing attention from the House.

The Trumpcare vote is going to be one tough choice

Rebecca Zisser / Axios

Republican leaders insist they're on a rescue mission, but Caitlin Owens and Bob Herman report this morning that most Republicans face a terrible choice no matter which way they vote. It's one of those rare cases where the far right, the left, and nearly all of the major health care industry groups agree it's a bad bill (for different reasons). So they can go against all of those groups — and risk voting for a bill that risks massive coverage losses — or they can vote against it and get hammered for backing away from seven years of repeal promises. Read their story here.

Diane Black's message: "Stay in the fight"

I caught up with House Budget Committee chairwoman Diane Black yesterday, who's about to manage the floor debate on the health care bill tomorrow. (And no, she doesn't know how late the vote is going to be.) She's spreading a simple message to her Republican colleagues who don't like the bill: "Stay in the fight." Don't vote "no" and kill the bill, she says. The Senate can make more changes than the House can, she points out — hinting that it might be up to them to push the parliamentarian to let them knock out Obamacare's insurance regulations.

Black didn't sound that worried about the vote, and insists she's hearing "less and less angst" about the bill than she did two weeks ago. But the whole "stay in the fight" pitch shows she's taking the opponents' threats seriously. And about the Trump visit yesterday? She called him "kind of a cheerleader." Read the interview here.

Why deductibles would rise under the GOP plan

Data: Kaiser Family Foundation analysis; Chart: Andrew Witherspoon / Axios

We're proud to have a new contributor: Drew Altman, the president and CEO of the Kaiser Family Foundation. Maybe some of you wonks have heard of him. This morning, he has a piece that looks at an underreported problem with the Republican health care bill: deductibles would rise, not fall. According to the foundation's analysis of the Congressional Budget Office estimates, deductibles would be $1,550 higher than they would have been under the Affordable Care Act.

That's because of a chain reaction of events: people would increasingly move to cheaper plans with higher deductibles, insurers would mostly offer only those plans, and the ACA's cost-sharing subsidies would disappear. We're looking forward to more of Drew's respected and evenhanded takes as the repeal effort moves ahead. Read his first piece here.

Pelosi's "Trumpcare Member Battle Plan"

Here's how the Democratic counterprogramming is going to go, according to an email House Minority Leader Nancy Pelosi sent to her caucus last night:

  • Press event with former Vice President Joe Biden this morning to mark the seventh anniversary of Obamacare.
  • Democrats are being "encouraged to use all available time to speak out against the Republican bill" in the Rules Committee and on the House floor.
  • On Thursday, there will be a "Facebook Live War Room" in her office.

The big question: What will former President Barack Obama say on Thursday? (The guy who was named after Obamacare.)

The Cleveland Clinic’s finances explain a lot

If you want to see a microcosm of the hospital industry, look no further than the Cleveland Clinic. Bob Herman reports that the not-for-profit academic health system's operating income plunged a whopping 71% in 2016 to $139 million, according to new audited documents.

Three big reasons why: higher labor costs but fewer inpatient admissions and surgeries, soaring drug costs, and high-deductible plans. The Cleveland Clinic has sounded the alarm on high deductibles for a couple years now, telling bondholders that those "balances continue to grow and are more difficult to collect than traditional insurance payors."

Yes, but: Cleveland Clinic's operations suffered, and those are all real problems. But after factoring in investment returns, the system still netted more than a half-billion dollars in income. It's rural hospitals, not academic or suburban ones, that are struggling the most right now.

What Price can and can't do on essential benefits

Price has told House Republicans that one of his next regulatory actions on Obamacare will be to ease the "essential health benefit" requirements. Thing is, though, there's not a lot he can do on his own. Unless Congress changes the 10 categories of benefits that are written into law, or the percentages of health expenses that have to be covered, HHS can't just rewrite them to bring down costs.

However, there are changes Price could make at the margins, and conservative health policy analyst Chris Jacobs has written that they could be significant enough to lower people's premiums. The two most likely possibilities: give states more flexibility to determine what satisfies the essential benefit requirements, and more variation for the "actuarial value" standards that determine how much of the expenses have to be covered. (The House GOP bill would repeal the actuarial value rules, but it doesn't get rid of any of the benefit categories.)

What we're watching today: House Rules Committee meets on the Obamacare replacement bill, 10 a.m. Eastern. Maybe a new Congressional Budget Office estimate, too. The House will also vote on bills to eliminate the antitrust protection for insurance providers and create association health plans.

What we're watching tomorrow: I don't know...a health care vote in the House?

Thanks, and let me know what your whip counts are showing: david@axios.com.

Featured

Trumpcare staggers toward its big day

Greg Ruben / Axios

It's almost time for Trumpcare to go to the floor! But first, who's ready for another really long day in a committee hearing room? That's great, because the Rules Committee is ready to spend many hours talking about amendments that will never get a vote. Unless they decide to give the Freedom Caucus one floor vote to make them happy.

Here's what to watch today:

  • The Rules Committee meets at 10 am to plow through more than 20 amendments, most of which will never go to the House floor. But there's one substitute by Freedom Caucus member Mo Brooks that would completely repeal Obamacare, so watch to see if he gets a vote. Same with Rep. Joe Barton's amendment to end Medicaid expansion faster.
  • Health and Human Services secretary Tom Price is signaling to his former House colleague that the administration is done negotiating on amendments. "At some point, you've got to put down the pens, and the hour is late," he said yesterday on the Hugh Hewitt show.
  • President Trump is sure to keep working on Republicans himself, following his visit to Capitol Hill yesterday and a meeting with moderate Republicans at the White House.
  • Trump has made progress in winning over moderates, and some conservatives are dropping their opposition because of the latest changes to the bill — including Rep. Gary Palmer of Alabama, who voted against the bill in the House Budget Committee but now supports it.
  • There are still a lot of holdouts, even after the Trump visit. Republicans can only lose 21 votes, and multiple reports suggested they're currently losing more than that. (The New York Times reports they could be short by as many as three dozen votes.)
  • From a leadership source late yesterday: "We are moving members. Going in the right direction. Still working."
  • Two powerful conservative groups — Heritage Action and Americans for Prosperity — oppose the bill and are making this a "key vote," meaning they'll keep track of any Republicans who vote for it. (The National Right to Life Committee, however, is supporting it.)

Oh, and don't forget the Senate, where they can't lose more than two Republicans. So here's three who are opposing it: Sens. Susan Collins, Rand Paul, and now Mike Lee, who tweeted yesterday that "I am a no." Wait your turn, Senate. Stop stealing attention from the House.

Featured

Trumpcare staggers toward its big day

Greg Ruben / Axios

It's almost time for Trumpcare to go to the floor! But first, who's ready for another really long day in a committee hearing room? That's great, because the Rules Committee is ready to spend many hours talking about amendments that will never get a vote. Unless they decide to give the Freedom Caucus one floor vote to make them happy.

Here's what to watch today:

  • The Rules Committee meets at 10 am to plow through more than 20 amendments, most of which will never go to the House floor. But there's one substitute by Freedom Caucus member Mo Brooks that would completely repeal Obamacare, so watch to see if he gets a vote. Same with Rep. Joe Barton's amendment to end Medicaid expansion faster.
  • Health and Human Services secretary Tom Price is signaling to his former House colleague that the administration is done negotiating on amendments. "At some point, you've got to put down the pens, and the hour is late," he said yesterday on the Hugh Hewitt show.
  • President Trump is sure to keep working on Republicans himself, following his visit to Capitol Hill yesterday and a meeting with moderate Republicans at the White House.
  • Trump has made progress in winning over moderates, and some conservatives are dropping their opposition because of the latest changes to the bill — including Rep. Gary Palmer of Alabama, who voted against the bill in the House Budget Committee but now supports it.
  • There are still a lot of holdouts, even after the Trump visit. Republicans can only lose 21 votes, and multiple reports suggested they're currently losing more than that. (The New York Times reports they could be short by as many as three dozen votes.)
  • From a leadership source late yesterday: "We are moving members. Going in the right direction. Still working."
  • Two powerful conservative groups — Heritage Action and Americans for Prosperity — oppose the bill and are making this a "key vote," meaning they'll keep track of any Republicans who vote for it. (The National Right to Life Committee, however, is supporting it.)

Oh, and don't forget the Senate, where they can't lose more than two Republicans. So here's three who are opposing it: Sens. Susan Collins, Rand Paul, and now Mike Lee, who tweeted yesterday that "I am a no." Wait your turn, Senate. Stop stealing attention from the House.

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Budget Committee chairwoman to Trumpcare holdouts: "Stay in the fight"

J. Scott Applewhite / AP

House Budget Committee chairwoman Diane Black got the Obamacare replacement bill through her committee last week (barely), and now she's about to manage the floor debate tomorrow. So she's been talking some of her colleagues through the tough vote ahead, with one simple message: "Stay in the fight." If they have problems with the bill, she says, the House is already making some changes, and the Senate can work on pieces the House can't touch.

When we talked yesterday afternoon, Black said she's hearing "less and less angst" about the bill than she was two weeks ago — but she knows there are still conservatives who want to wipe out Obamacare's costly insurance regulations, and she's hinting that the Senate might be able to take those on more easily than the House.

Read on for the highlights of our interview, which has been condensed and edited for brevity.

How confident are you that this will pass?

" I'm really delighted about where we are." All four of the Budget Committee's non-binding recommendations were addressed in some way in the GOP leadership's changes to the bill, and those will help win support.

" I'm just encouraging everyone to stay in the fight. We're still in the earlier stages. Obviously it will look different when it comes back from the Senate."

Who are you talking to?

House members who still have concerns, but the GOP leadership's changes have helped: "For the most part, I'm hearing less and less angst about the product and voting for it on Thursday than I was, say, two weeks ago."

How did President Trump's visit go this morning?

"You know, the president, he's kind of a cheerleader. He really wants to see us move forward on what we've promised the American people ... And so I think he's there to say, 'Let's get the job done.'"

What do you say to Freedom Caucus members who are upset that the bill doesn't tackle costs by getting rid of Obamacare's insurance regulations?

"I say, 'stay in the game' ... There are certain things we can do here, and there are other things that potentially can be done over in the Senate." They're limited by the "Byrd rule," which keeps them from considering non-budgetary changes in the "reconciliation" bill that only needs 51 votes in the Senate. "If we didn't have the Byrd rule, we could be doing all of this at one time."

"Of course, the parliamentarian doesn't need to speak to us, and so it'd be a whole lot easier for some of our senators to raise some of these other concerns that we're not necessarily able to do within our measure."

What about the moderates' concerns that the low-income elderly wouldn't get enough financial help?

"I think that is being fixed as we speak" through the reserve fund that could give the Senate enough money to beef up the tax credit.

Are you worried that the Republicans will own whatever happens with the health care system after this vote, whether it's caused by this legislation or not?

"Will there potentially be some things that, once the patient goes home, that we still have to address? I would say so. I don't know of any perfect piece of legislation ... There may be at some point in time something we have to tweak here and there, and we'll be ready to do that. But you've got to patch the patient up first."

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Conservative heavyweights square off on Trumpcare "key voting"

Evan Vucci / AP

This is the time when key conservative groups are announcing that the House Republican health care bill will be a "key vote" — meaning they're keeping track of how every member of Congress votes, and if they don't vote the way the group wants, their supporters are going to hear about it.

But what are Republicans supposed to do when two of the most powerful conservative interest groups are on opposite sides?

  • Against: Heritage Action — because the bill doesn't repeal Obamacare's insurance regulations.
  • For: National Right to Life Committee — because it would keep tax credits from being used to pay for abortions, and defunds Planned Parenthood.
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A former Tom Price colleague will handle health tech for HHS

AP file photo

Didn't see this one coming: former Rep. John Fleming is going to join Health and Human Services secretary Tom Price's team as the new deputy assistant secretary for health technology, NOLA.com reports. How does Price know him? Fleming was a vice chairman of the GOP Doctors Caucus, the group Price belonged to when when he was in the House.

Fleming says he wants to encourage doctors to use technology rather than considering it a headache. He wants to make it easier to transfer information to new digital filing systems and give incentive payments to doctors who use technology.