Axios - Health Care
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Reports: Trump routinely confuses Medicaid and Medicare

Evan Vucci / AP

A Republican Senator told the New York Times on Tuesday that President Trump gave the impression that he "did not have a grasp of some basic elements of the Senate plan" and that he was "especially confused" by the idea of opponents calling the bill "a massive tax break for the wealthy." More aides described Trump as uninterested in the particulars of health care.

"There would be times when he would describe what was clearly Medicare...but say Medicaid, and when we pointed that out, he would say, 'That's what I said, Medicare and Medicaid."
  • When asked if Trump had an understanding of the important aspects of the House and Senate health care bills, a close aide laughed and replied, "not to my knowledge."
  • "The president understands winning," a different official said.
  • Aides don't point out Trump's misunderstandings, not wanting to make him feel or look "dumb."
  • On Trump's campaign promises about repealing and replacing Obamacare, a former campaign aide said, "It wasn't really a policy oriented campaign—policy wasn't on our radar. The sense was, say what wins and figure out the details later."
  • Just as his intelligence briefings have been cut short compared to those of Obama, an official told the Daily Beast, "It is fair to say the president takes [a] similar approach to health care... [It's] 'less is more.'"
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The story behind Trump's Medicaid tweet

On Wednesday afternoon, President Trump tweeted a graph from his personal account showing Medicaid spending under the Republican Senate health bill.

There's a story behind that tweet: In the Oval Office on Wednesday, Marc Short, the White House Legislative Affairs director, showed Trump a piece of paper with the graph of Medicaid spending pointing up. Trump wanted to tweet it, according to a source told about the meeting.

Why it matters: The graph doesn't show the other side of the Medicaid changes: the fact that spending would go down compared to current law, which is how Senate Republicans get $772 billion in savings. That's the whole point of the new spending limits.

This is all part of a broader White House strategy: They want to change the way it's presented in the media to help sway some of the Senate Republican holdouts.

  • For the longest time, Republicans in all branches of government failed to frame the argument over Medicaid in terms of the Medicaid dollars going up. Some in the administration had concluded it was an argument they couldn't win. But a number of officials saw they were getting killed every day in the press, with reports of the billions being cut out of Medicaid. Some officials wanted to aggressively reframe the argument as a growth in spending — and a slowing of the growth rate under Obamacare rather than a raw "cut."
  • Even at this late stage, the White House believes it's crucial to change the media narrative. A number of officials believe that some crucial senators are more heavily swayed by media coverage than they are by the substance of the cuts to the Medicaid spending under the Affordable Care Act.

HHS Secretary Tom Price has been making this argument, and tweeted a similar graph of Medicaid spending on Tuesday:

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No one came out of yesterday's Senate GOP meeting sounding hopeful

David J. Phillip / AP

Senate Republicans spent a whole lot of time talking about the health care bill yesterday, but not a whole lot of time reaching any deals. That makes it harder to see how they could get an agreement by Friday on a revised bill.

It didn't help when Sen. Ted Cruz said he wants to let insurers sell plans that don't have any protections for pre-existing conditions — as long as they also sell plans with that offer those protections and follow the Affordable Care Act's other insurance rules.

Reaction to Cruz's comment:

  • One Senate GOP aide told Caitlin Owens that many of the Republican senators were "surprised and pissed" because most Republican senators had already agreed not to touch the ACA's pre-existing condition protections.
  • Another aide summed up: "No matter how narrowly-proposed, wading into pre-ex is not just a 'No,' it's a 'Hell No' for the vast majority of the Senate GOP."
  • A Cruz spokesman, however, said the senator has been talking for weeks about the idea, which is part of a proposal to give consumers a choice between health plans that meet all of the ACA rules and plans that don't. He's been handing out a card that includes that pitch.

No one came out of yesterday's Senate GOP meeting sounding hopeful.

  • Sen. Susan Collins: "It's very difficult...I'm concerned about a number of aspects, such as coverage, Medicaid cuts, impact on premiums."
  • Sen. Shelley Moore Capito: "I'd like to see a [Medicaid] growth rate that matches the projected growth, or at least is close to projected growth." She also wants $45 billion in opioid treatment money over 10 years.
  • Sen. Rob Portman: "I'd rather see us stick to the [Medicaid] growth rates that were worked out by the House."
  • Sen. Rand Paul: Any tradeoff that gives more money to moderates and more deregulation to conservatives "sounds to me like a Washington deal...I'm not going to go for that."

Most of the optimism is coming from the White House. Here's how an administration source summed up the mood to Jonathan Swan last night: "I think we're going to pass this. I really think they'll bribe off the moderates with Opioid money and then actually move policy to shore up Mike Lee and Ted Cruz."

This is how it's going: Even Sen. John McCain, who hasn't been one of the most vocal holdouts, says he's not ready to vote for the bill. Since he's from Arizona, which expanded Medicaid, he wants to offer three Medicaid amendments that he's worked out with Gov. Doug Ducey.

"That has a lot to do with whether I support the bill or not," McCain told reporters as he stepped into an elevator. When asked what the amendments were, he motioned to the elevator operator to hit the button: "Basement!"

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How the Senate health bill would change Medicaid funding

The Senate health care bill would substantially reduce federal funding for all Medicaid beneficiary groups over the next two decades compared to current law, according to an analysis by Avalere, a health care consulting firm.

Why this matters: The funding cuts could encourage states to cut benefits for enrollees, payments to providers or eligibility for the program. It also saves the federal government $772 billion over 10 years, and likely much more over 20 years.


Data: Avalere Health analysis; Note: Adult age cutoff defined by state, ranging from 19-21. Seniors are 65+; Chart: Andrew Witherspoon / Axios

What the bill does:

  • Phases out enhanced federal funding for the Affordable Care Act's Medicaid expansion.
  • Caps the amount of federal funding per Medicaid enrollee. This cap grows with medical inflation beginning in 2020, but in 2025 the growth rate slows to inflation, which is tighter and causes most of the steep reductions.

Go deeper: How the Senate health bill would change insurance premiums, broken down by location, age and income.

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GOP health plan losing support among Trump voters

Senate Republicans have an urgent reason not to give up on repealing and replacing the Affordable Care Act: They don't want to break their promise to the GOP base. But the most recent polls suggest the base may not care as much as Republicans think.

The bottom line: A majority still supports the plan, but support has slipped, and there is some evidence that base Trump voters do not view repeal as a top priority — and many may not punish their representatives if they vote no.

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

The repeal push is motivated by several factors. Many Republicans in Congress want to undo whatever former President Barack Obama did. Some want to cap Medicaid spending. Others want to deliver a tax cut.

But the chief motivating factor is the desire to deliver on their campaign promise to the base to repeal "Obamacare," despite the problems with the legislation documented so thoroughly by the Congressional Budget Office. So it seems highly relevant to know where the base actually stands on the Republican replacement plan.

Consider these findings from our most recent June Kaiser Tracking Poll:

  • 55% of President Trump's supporters still support the Republican replacement plan, but, as the chart shows, that number is down a notable 14 percentage points from May.
  • Trump supporters still want Trump and Republicans to keep working on a plan to repeal and replace the ACA (75%). But only 8% cite it as the most important priority for them, similar to the share of the public at large.
  • Less than half of Trump supporters — 44% — say they'd be less likely to support a member of Congress who votes against the bill.

Why it matters: Republicans have been single mindedly focused on their base because they know that only the most dedicated slivers of the electorate come out to vote in midterm elections. These data show that Trump voter intensity on the replacement plan has fallen. The polling data are similar if you look at Republican voters overall, rather than Trump voters.

If the intensity continues to fall, it could diminish this expected turnout. At a minimum, it could make repeal a less effective tool to whip up turnout in the base.

What we don't know: The vote, whenever it happens, could significantly affect the base in directions that are difficult to predict. So could the impact of the law itself if it passes. The CBO predicts that premiums and deductibles in the non-group market will begin to rise sharply and quickly, and Trump voters will be among the groups affected.

It is possible, therefore, that the immediate Republican victory lap that would come from passing repeal could end as Trump voters start to pay their health care bills.

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The story behind Trump's Medicaid argument

President Trump's rallying behind the Senate GOP's health care bill continued this afternoon as he tweeted that the bill actually increases Medicaid spending rather than cutting it:

Our thought bubble: The Senate bill would cut Medicaid spending by $772 billion over a decade from its levels under the Affordable Care Act. Some Republicans argue, as the the New York Times summed up yesterday, that health care spending under the ACA is dangerously out of control, so the Senate bill doesn't include "cuts," it simply increases Medicaid funding at a more reasonable rate.

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Anthem's ACA exit in Nevada could leave bare counties

Michael Conroy / AP

Anthem will only sell health plans on Nevada's Affordable Care Act exchange in three counties next year: Clark (where Las Vegas is located), Nye and Washoe. The 14 counties Anthem is leaving could potentially have no ACA options in 2018 — making a total of 61 counties throughout the country that may have no insurers selling ACA coverage, per the Kaiser Family Foundation.

Why it matters: Anthem, one of the largest ACA insurers and a well-known Blue Cross Blue Shield brand, has already exited the exchanges in Indiana, Ohio and Wisconsin.

Yes, but: Kaiser Family Foundation data show that even though Anthem is exiting 14 total counties, the insurer will offer plans in Nevada's most populated areas that cover 90% of people in the individual market, raising questions about why Anthem chose to exit the state's more rural counties. (An aside: Anthem supports the Senate's health care bill, but Republican Dean Heller of Nevada currently does not.)

Featured

Houston hospital system cuts workforce

Wikimedia Creative Commons

Memorial Hermann Health System, the largest hospital system and employer in Houston, has trimmed its workforce by 460 people this year, the Houston Chronicle reports. The latest round of layoffs come a week after Dr. Benjamin Chu abruptly resigned as CEO.

Why it matters: Hospitals have been on a hiring binge since 2014, but the growth of employee costs has outpaced the revenue hospitals collect from Medicare, Medicaid and commercial insurers. Layoffs at hospitals are inevitable if that trend continues. Memorial Hermann, a not-for-profit system that has watched its operating income plunge 65% this year, wants to cut $500 million in costs over five years.

Worth noting: Dennis Laraway, Memorial Hermann's chief financial officer, told bondholders Wednesday the system's financial struggles also stem from Houston's struggling oil and gas economy, which has led to fewer high-paying jobs with private insurance.

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Rand Paul lays out health care demands

J. Scott Applewhite / AP

Sen. Rand Paul sent a letter on Tuesday to Majority Leader Mitch McConnell, laying out his "policy priorities" for the senate's new health care bill:

  • Allow small business plans or association health plans to self-insure.
  • Reconsider the "insurance company bailout," which he says will come to $136 billion.
  • Reconsider the premium tax credits policy proposed by BCRA.
  • Remove the "Republican version of the individual mandate" and allow insurance companies to impose a waiting period.
Why it matters: Senate Republican leaders don't really think Paul was ever "gettable," but the letter is a good example of the lengthy lists of demands we're likely to see from other Republican holdouts — because they know they have leverage.
One more thing: Paul got face-time with Trump at the White House yesterday, tweeting that the President is "open to making [the] bill better."
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Trump: will be "very tough" to pass health bill

Evan Vucci / AP

President Trump touched on health care during an energy roundtable Wednesday, saying he'd had a "tremendous meeting" yesterday with Republican senators, and that although the Senate bill will be "very tough" to get approved, he thinks the GOP will "get at least very close" to passing it, and will ultimately get it over the line. More from Trump:

  • "Obamacare is dying, it's essentially dead... It's been a headache for everybody, it's been a nightmare for many and we're looking at a health-care that will be a fantastic tribute to your country."
  • "It will be far better than Obamacare and much less expensive for the people and also much less expensive for the country."
  • From the WH pool: "Healthcare is working along very well...we're gonna have a big surprise. We have a great Healthcare package. ... we're going to have a great, great surprise."