David Nather
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The states that are running out of CHIP funds

Sixteen states are in danger of running out of federal funds for the Children's Health Insurance Program by the end of January if Congress doesn't renew funding — including California, Texas and Florida. Here's an interactive look at the states and how many children could lose health care coverage. (The ones whose coverage doesn't include Medicaid funds are at the greatest risk.)

The bottom line: This could still get solved in a spending bill for the rest of the year, but it's the kind of thing Congress could have finished months ago if they had focused on it, rather than fighting over Affordable Care Act repeal. The Centers for Medicare and Medicaid Services is giving states some temporary funds, but they won't last very long.

Data: Kaiser Family Foundation, MACPAC; Chart: Chris Canipe / Axios

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5 things that could trip up the spending bill

Trump next to empty seats for Schumer and Pelosi at an aborted spending meeting last month. Photo: Susan Walsh / AP

Sure, Congress wants to go home for the holidays. But it also has to fund the government after Dec. 22. And there are a lot of things that could go wrong.

Here's how plugged-in appropriations experts are ranking the dangers over the next two weeks:

  • Immigration: This is the biggest danger. Democrats will push hard for legal status for the "DREAMers" — people who are in the country illegally who came here as children. And there's no sign that Republicans are willing to put it in the year-end bill. "I don't see how a majority of this Congress leaves without some resolution," said Jim Dyer, a former House Appropriations Committee Republican staff director.
  • No tax deal before the spending bill: If Republicans can't pass a final version of the tax bill by Dec. 22, President Trump could easily pressure Congress to stay in town by refusing to sign a government funding extension until lawmakers finish the tax bill.
  • Defense vs. domestic spending: Democrats could make trouble if a funding bill includes a big boost for defense spending, but nothing for domestic programs.
  • CHIP funding: The Children's Health Insurance Program has expired, and Republicans had said the year-end bill was where its funding would be extended — but they still haven't figured out how to pay for it. Expect pushback from Democrats, and maybe governors, if it doesn't happen.
  • ACA payments: Republican Sen. Susan Collins wants two fixes for the Affordable Care Act — a bipartisan renewal of payments for insurers and a separate set of "reinsurance" funds — as a condition for her to vote for a final tax bill. That could cause problems if the House doesn't go along, which it probably won't.

One more thing: A larger problem, Dyer said, is "the general level of rhetorical excess" — partly driven by the White House.

  • His point: Most of the problems are solvable. It just takes cooler heads.
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The bill Republicans can’t not pass

Illustration: Rebecca Zisser / Axios

Why are Senate Republicans scrambling to pass a hastily rewritten tax bill that most Americans don't even like? Think of it as the mirror image of what Democrats did seven years ago with the Affordable Care Act. When it's a core issue for your party — as tax cuts are to Republicans, health care was to Democrats — you'd better be able to pass it.

The bottom line: When Republicans control the White House and both chambers of Congress, it would be hard to explain why they couldn't pass a rewrite of the tax code — every bit as central to their agenda as health care was to the Democrats when they controlled the White House and Congress. The details, and the polling, are almost beside the point.

The parallels between the tax bill and the Affordable Care Act are hard to avoid:

  • President Trump has been promising the tax bill since day one, and Republican leaders have been campaigning for tax cuts for years.
  • Barack Obama campaigned on the health care for the uninsured, and Democrats were eager to finish what they regarded as the last missing piece of the social safety net.
  • Trump and Republicans are especially eager to pass the tax bill after the embarrassing failure of their last major initiative (repealing the Democratic health care law).
  • Democrats were eager to pass health care after decades of failures, including the collapse of Bill and Hillary Clinton's health care effort in 1994.
  • A Republican president and Congress give them the best shot at tax cuts that they're going to get, just as Democrats knew they'd never get a better shot at health care than they had in 2010.
  • The polling is historically bad for the tax bill — but it was for the health care bill too, by the time Democrats were ready to pass it. Republicans are going ahead with the tax bill because they know it's popular with a majority of their voters, just as health care was with most Democratic voters.

Where they're different:

  • Senate Democrats rewrote their health care bill on the floor — largely behind closed doors — to get enough votes. That's what Republicans are doing now. But the Democrats took days, while the Republicans are doing it in just hours.
  • A former Senate Republican aide who worked on the health care bill notes that the rewrite by Senate Democrats took "the entire month of December" (here's a good recap from The Washington Post). The Republican tax bill rewrite happened overnight.
  • The Democrats finished their health care bill through the budget "reconciliation" process, which only required 51 Senate votes. But that happened after the Senate passed its initial version with 60 votes — and then had to make the final tweaks through reconciliation after Democrats lost their 60-seat majority. Republicans are using the process from beginning to end.

What to watch: Remember how Democrats took the blame for everything bad that happened with health care after they passed the ACA by themselves, and had trouble getting any credit for the good stuff? If Republicans rewrite the tax code by themselves, they're going to own it, too.

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ACA enrollment edges up to 2.8 million

Open enrollment this year is only half as long as last year. Photo: AP file

Nearly 2.8 million people have signed up for Affordable Care Act coverage for next year in the first four weeks of open enrollment, according to figures released by the Centers for Medicare and Medicaid Services today. That includes roughly 718,000 new customers and nearly 2.1 million who were renewing old plans.

Yes, but: That’s a long way from the 12.2 million people who signed up for 2017 coverage. And open enrollment this year only runs through Dec. 15 — half as long as last year’s enrollment season.

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The tax bill’s not looking so popular

The GOP may be heading for more trouble with its legislative agenda — this time with an unpopular tax bill. A compilation by Chris Warshaw of George Washington University of various polls shows that the plans to rewrite the tax code are only slightly more popular than the Affordable Care Act bills that narrowly failed — and both are among the least popular legislative proposals of the last three decades.

Reproduced from a chart by Chris Warshaw, assistant professor of political science at George Washington University; Chart: Axios Visuals

Why it matters: Republicans really can't afford to give up on the tax bill, after suffering an embarrassing defeat on their health care effort. But when something is as central to their agenda as the tax rewrite, they're going to have serious headaches if they can't win more support with the public.

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Why you should care about “chained CPI"

Senate Finance Committee chairman Orrin Hatch begins the committee’s work on the tax bill. Photo: Pablo Martinez Monsivais / AP

The Wall Street Journal’s Greg Ip has a smart story about the new inflation measure that’s included in the House and Senate tax bills. Instead of the Consumer Price Index, which economists believe overstates the cost of living, it would use a measure called “chained CPI,” which may be more accurate, but also rises more slowly than the regular CPI.

Why it matters: Some people will get pushed into higher tax brackets faster than they would have under the old measure. It helps Republicans pay for the tax bill, because it’ll raise $130 billion in revenue over 10 years. But it’s also safe to say that most Americans who aren’t tax experts will have no idea of the impact until it hits them.

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Maine governor not ready to expand Medicaid

LePage says the legislature will have to fund the expansion first. Photo: Robert F. Bukaty / AP

Not so fast, Maine voters. Gov. Paul LePage says his administration won’t expand Medicaid until the state legislature funds it, after the state voted last night to broaden the program under the Affordable Care Act, per the Bangor Daily News.

The bottom line: It’s not surprising that LePage would pump the brakes, since he vetoed Medicaid expansion five times. But the voters overruled him last night, so even if the state doesn’t expand Medicaid now, it will eventually.

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How cancer survival rates have changed since the 70s

More people are surviving a cancer diagnosis today than in the 1970s, according to a report released earlier this year by government agencies and cancer groups. That's the good news facing former Vice President Joe Biden, who's speaking with Mike Allen at an Axios event in Philadelphia today, as he continues his work to speed the progress of cancer research.

But the survival rates are still low for several kinds — including brain cancers like the type that killed his son, Beau Biden.

Data: Journal of the National Cancer Institute; Chart: Chris Canipe / Axios

What's next: Immunotherapies are one promising area of cancer treatment, but there are questions about why checkpoint inhibitors (one class of immunotherapeutic drugs) work in some patients but not others. These treatments, and others known as CAR T-cell therapies that involve changing a patient's own immune cells so they will attack cancerous cells, can also cause serious side effects that researchers are racing to understand.

Dr. Elizabeth Jaffee of Johns Hopkins University, president-elect of the American Association for Cancer Research, says these are the most likely advances in immunotherapy to watch over the next few years:

  • Developing "accelerator" therapies to help the immune system activate more quickly.
  • Activating T-cells that have never been activated before by targeting monocytes, a type of white blood cell.
  • Inhibiting molecules formed when T-cells metabolize so the immune cells can better respond to cancerous ones.

Keep in mind: For breast, prostate and a handful of other cancers, increased screening and early detection may have improved survival rates while masking only minor gains in longevity. Prevention is how we've made the most headway in decreasing actual death rates from cancer — with fewer people smoking, for example — and where more progress can be made.

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Paul suffered five broken ribs in attack

Paul’s injuries are more serious than first believed. Photo: Timothy D. Easley / AP

The attack on Sen. Rand Paul at his home on Friday left him with five broken ribs, and it’s not clear when he’ll be able to return to the Senate, per AP. Senior adviser Doug Stafford told AP that Paul is in a lot of pain and would have trouble flying, an account that indicates Paul's injuries were more serious than the initial reports suggested. Police have charged one of Paul’s neighbors — Rene Boucher, 59 — with misdemeanor fourth-degree assault.

The big picture: The assault on Paul follows a series of attacks and threats against other lawmakers — most notably the shooting of House Majority Whip Steve Scalise at a congressional baseball practice this summer. The Washington Post reports that Rep. Frederica Wilson, who criticized President Trump’s phone call to the widow of a soldier killed in Niger, has been the target of threats since then.

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Anthem CEO reportedly stepping down

Swedish has presided over a failed merger attempt with Cigna and a pullback from ACA markets. Photo: Jacquelyn Martin / AP

Anthem CEO Joseph Swedish is expected to step down, and former UnitedHealth Group executive Gail Boudreaux will be named to replace him, the Wall Street Journal reports. The move could be announced as early as next week.

Why it matters: His last couple of years as the head of Anthem will be remembered for two things: a failed attempt to buy Cigna and a pullback from many Affordable Care Act markets. Overall, though, he’ll leave Anthem in good shape. Its ACA enrollment for next year is expected to be way down, but it predicts increased enrollment in big businesses like Medicare, Medicaid and self-insured employer plans.