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Trump wants changes to health care deal

The Trump administration is pushing for a "rightward shift" in the Senate's bipartisan health-care bill, the Washington Post reports, citing people briefed on the matter. The White House wants retroactive relief from the ACA's insurance mandate.

Why this matters: The Post reports nothing has been decided and negotiations continue, but the White House demands "could derail the carefully crafted bipartisan package unveiled this week."

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After dropping for 3 years, uninsured rate rising

A doctor and patient at a health clinic in Oregon. Photo: Gosia Wozniacka / AP

After consistent declines over the past three years, the rate of U.S. adults without health insurance has begun to rise, according to new data from Gallup. One year ago, the uninsured rate was 10.9%, down from 18% in early 2013. Now, it has ticked back up to 12.3%, the highest percentage recorded since 2014.

Why it matters: The steep drop in the uninsured rate was one of the Affordable Care Act's biggest successes since it went into full effect. If that's being reversed now, expect a lot of debate over how much is because of the months of repeal efforts and the Trump administration’s vocal opposition to the law.

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Senate largely ignoring Trump's flip-flopping on health care

The Senate isn't taking President Trump's constantly-changing position on the health care bill very seriously. Photo: Evan Vucci/AP

President Trump keeps flip-flopping on whether he supports a bipartisan bill to stabilize health care markets. And it has created a weird dichotomy in the Senate: No one's taking his position on the bill very seriously at any given moment, even though it needs his support to pass and become law.

Bottom line: There's a lot of enthusiasm in the upper chamber for this bill, sponsored by Sens. Lamar Alexander and Patty Murray, and not much weight is being given to Trump's vacillating opinions.

"In this town, at this time, change seems to be the norm," Sen. Pat Roberts told me when asked if members take the president's position less seriously the more he changes his mind. "It is what it is. So we just work around it."

What's happening: At first, the president's flip from being supportive of the deal to tweeting that it's an "insurer bailout" seemed to rattle its prospects for passage. But on Thursday, Alexander and Murray pushed ahead, introducing the bill with 24 cosponsors. As the president's position continued to shift — seemingly by the hour — some senators were even cracking jokes about it.

  • At the beginning of my question on the president's changing positions, Sen. Johnny Isakson quipped: "Which one's he on now?" He told me that even with the president's shifting support of the bill, "I'm moving it ahead to try to get it in a position where if it's signed, it's a good law for Georgia."
  • When asked if Trump changing his mind so much made it hard to predict where he'll land on the bill, Sen. Jeff Flake said, "I think that's rather obvious."
  • "They just need to pass it during the 5 minutes he is supportive," one GOP lobbyist told me.
On a serious note: What Trump says right now isn't the most important thing, Sen. John Thune said: "In the end it's going to be what he does. And if he comes out actively, gets behind it, tries to help get votes for it, and then if he announces that he'll sign it, that sort of thing, I think those are the type of messages that will help bust it loose."
Yes, but: The Senate may be plowing ahead with its work on the bill, optimistic the president will be supportive when they need him, but the bill really can't become law without him — because of the obvious necessity that he sign it, but also because his support will likely mean a lot more to House Republicans. If Trump can take advantage of that, he really could have some leverage.
  • "What I would do if I were in his shoes is, I'd read it, and then I'd try to improve it," said Alexander, whom Trump called twice on Wednesday to offer encouragement.
  • "He's president of the United States and I take him seriously, and I'm a member of the Senate and he takes me seriously," Isakson said. "But the fact that he's vacillated some, that's the luxury you have when you're president."
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The pitch for a health DARPA

A lung on a chip developed by Harvard University Wyss Institute on a DARPA grant. Photo: DARPA

The Defense Advanced Research Projects Agency is known for creative, high-tech research projects that often sound like science fiction. Now, a philanthropic heavyweight and a former DARPA program director together are pushing for the federal government's health department to have its own version.

The big questions: How would it fit in the health department that also includes the National Institutes of Health? And how will pharmaceutical and other companies be incentivized to take products to market? The answers — and some clever navigating of the potential tensions — could help determine whether an Advanced Research Projects Agency for Health, or HARPA, ever gets off the ground.

The players: Bob Wright, the former CEO of NBC and founder of Autism Speaks, is the main force behind the proposal. He's tapped Geoffrey Ling, a neurologist at Johns Hopkins and the former director of DARPA's Biological Technologies Office, to develop the proposed agency and, Wright hopes, lead it.

DARPA gave us the internet, and both say it is worth seeing what the same model could do for much-needed advances in detecting and treating cancers and other diseases.

How it could work: Ling maintains it would complement the discovery work done at NIH: "I'm not saying that HARPA is a panacea and is going to fill all the need areas but it is an approach I can see filling part of these need areas. In my mind, it is just a different way of doing business. It's an entirely different philosophy."

The details: They advocate setting up a semi-autonomous body directly under the Department of Health and Human Services — but independent from NIH.

  • HARPA, like DARPA, would be "performance-based, milestone-driven, timeline-driven with the efforts determined by the government," Ling says.
  • It would center on contracts between the agency and researchers spanning academia, corporate and government agencies.

Harvard's David Walt, who is not involved in the proposal and was a chair of a now-defunct advisory council of DARPA, says if an ARPA health program is set up correctly and follows the DARPA model closely, it could benefit the health arena. But he points out that health care is a highly regulated environment. "I'd be excited about the prospect of bringing a DARPA-like approach to critical problems in health care but it isn't the same as implementing a new device in the military."

What NIH is doing: Taking science from the "bench to bedside" is within the NIH purview — director Francis Collins set up an institute to do just that. And, right now, the NIH can bypass the grant process and distribute funds through a DARPA-like arm called the Common Fund. Their 2017 budget is about $675 million.

About two-thirds of the work within that fund is toward goals set by the NIH with investigators coming up with ways to attempt to reach them, says Betsy Wilder, who directs the Office of Strategic Coordination at the NIH. DARPA also funds biotechnology projects and collaborates with NIH.

The ask: Wright and Ling want two separate chains of command under HHS and two separate budgets within the department.

  • Ling estimates the agency would require a budget of $2 to 3 billion — the equivalent of about 10% of the NIH's $34 billion for this year.
  • "We'll be the little sister to the NIH. No problem. But because of the different philosophy and because of the different approach, it needs to go up a separate chain of command. That is absolutely crucial because otherwise it's going to be viewed as competitive and that just isn't right. It's synergistic," Ling says.
  • The $6.3 billion 21st Century Cures Act authorized by Congress last year could help to launch HARPA, Wright says. Right now, $4.8 billion is slated to go to the NIH and $1 billion to states for opioid treatment and prevention.
  • Wright says, HARPA's success would depend on its ability to use NCI databases and other government assets.

Where it stands: "We've gone to the White House, we've gone to Congress, we've got bipartisan support," Wright says.

Ultimately, it would require congressional authorization — but they're asking the White House to launch it, potentially on a pilot basis. President Trump's budget proposed cutting money for the NIH, and there is a general trend toward consolidating across the federal government, raising questions about where funding for a new program would come from.

What we don't know: Where this will go. A spokesperson for the White House said there was no comment at this point.
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Senate Republicans try to flip Trump on Alexander-Murray

Senate Majority Whip John Cornyn speaks with Sen. Lindsey Graham at a hearing. Photo: Andrew Harnik / AP

Senate Republicans are urging the president to back the bipartisan Alexander-Murray deal to stabilize insurance markets, Politico reports. The White House said Wednesday that Trump does not support the bill in its current form.

What they're saying:

  • Sen. Lindsey Graham told Trump, "You can't save Obamacare but you can keep the markets from collapsing until we get a replacement, which will be Graham-Cassidy ... I just don't see a transition to Obamacare to a block grant that doesn't require at least a couple years to implement." Trump has said his ultimate goal for health care reform will involve block grants to the states, like the Graham-Cassidy plan.
  • Sen. Lamar Alexander said he's spoken to the president four times in the last 10 days about his bill.
  • Sen. John Cornyn said, "I don't think there's any chance of passing it without the president's support."
  • Sen. John McCain said, "If there's a package that's supported by the majority of the American people and the Congress, then we will pass it," signaling he thinks the president's opposition shouldn't matter.
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Alexander, Murray announce 24 cosponsors for health bill

Sens. Lamar Alexander and Patty Murray announced their bill has 24 cosponsors. Photo: J. Scott Applewhite/AP

Sens. Lamar Alexander and Patty Murray introduced their bipartisan individual market stabilization bill on Thursday and announced it has 24 cosponsors.

Why it matters: This bill could pass the Senate — if it comes up for a vote.

Republican sponsors: Alexander, Sens. Mike Rounds, Lindsey Graham, John McCain, Bill Cassidy, Susan Collins, Joni Ernst, Lisa Murkowski, Richard Burr, Bob Corker, Johnny Isakson, Chuck Grassley

Democratic sponsors: Murray, Sens. Angus King, Jeanne Shaheen, Joe Donnelly, Amy Klobuchar, Al Franken, Heidi Heitkamp, Joe Manchin, Tom Carper, Tammy Baldwin, Claire McCaskill, Maggie Hassan

Key quote: Given the policies included and the various sponsors, Alexander said, "Sounds like something that might actually become law before the end of the year."

To opponents of the bill: "Some people are still objecting to the idea of continuing" cost-sharing reduction payments for two years, Alexander said: "They're listening to groups around Washington, D.C. I would suggest they listen to some other people" who could be hurt if the payments don't continue.
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Don’t rush to judgment on Alexander-Murray

Alexander and Murray may have another chance in December. Photo: J. Scott Applewhite / AP

Yes, the Senate's bipartisan Affordable Care Act bill ran into some political roadblocks yesterday. The White House said President Trump, who had taken several positions over the course of the day, is against it. House Speaker Paul Ryan is also against it. And conservatives are against it.

Why it doesn't matter: The story of the Alexander-Murray bill likely won't be over until December, when Congress has to take care of several must-pass bills, in negotiations where Democrats have a lot of leverage.

  • The December agenda already includes funding the government and raising the debt ceiling — must-pass items that can only pass with a lot of Democratic votes, just like Alexander-Murray.
  • If Alexander-Murray doesn't pass before then, it's pretty easy to see Democratic leaders insisting on some form of Affordable Care Act stabilization as part of the end-of-year package. And this bill, or something close to it, is likely the best Republicans are going to get.
  • As one senior GOP aide told to my colleague Caitlin Owens: "At some point McConnell and Ryan will need this."

The catch: The Alexander-Murray bill would guarantee funding for the ACA's cost-sharing subsidies, but it doesn't provide for retroactive payments. So if the bill did pass in December, insurers wouldn't get any help with the financial hit they'll take between now and then. And those losses alone could total $1 billion.

In the meantime, look for Alexander and Murray to roll out a new, bipartisan roster of cosponsors today, along with the official introduction of their bill.

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The Hepatitis C epidemic following the opioid crisis

Cases of Hepatitis C have almost tripled in the past few years, according to the Center for Disease Control and Prevention — an effect of the opioid crisis and the unsanitary use of needles by drug users. There were 2,436 reported cases of the liver disease in 2015, up from 853 cases in 2010.

Data: Centers for Disease Control and Prevention; Chart: Chris Canipe / Axios

Why it matters: Hepatitis C can be deadly if not treated, and treatment can cost tens of thousands of dollars. Americans will be paying for the opioid crisis for years to come, with the total tab coming to an estimated $100 billion.

"If we don't cure a significant number of the people who are injecting, in 20 years from now, the hospitals in this part of the world will be flooded with these people with end-stage liver disease, which has no cure," Judith Feinberg, professor at the West Virginia University School of Medicine, told the Washington Post.

Political solutions: There have been some state and local efforts to establish "syringe exchanges," which offer drug users clean syringes as a way to prevent the spread of Hepatitis C. These controversial programs are now legal in some states like North Carolina, New Hampshire and Vermont, but have recently been shut down in counties in Utah and Indiana.

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Trump’s mixed signals on health care deal

Trump met with Senate Finance Committee chairman Orrin Hatch and other committee members this morning. Photo: Susan Walsh / AP

White House press secretary Sarah Huckabee Sanders now says President Trump doesn't support the bipartisan Senate health care deal in its current form. That should settle questions about his position for now, but that's after 24 hours of mixed signals that left some of his own advisers unclear where he really stands, as recently as this morning.

What we're hearing: Before Sanders' briefing this afternoon, a senior administration official told us that everyone is hearing what they want to hear, and nobody knows exactly what Trump wants from hour to hour or where he will land. To some extent, his own advisers are never completely sure. But it's fair to say that everyone who is remotely conservative inside the administration is pushing not to keep funding the Affordable Care Act's insurer subsidies without serious concessions.

What's at stake: The deal by Sens. Lamar Alexander and Patty Murray would fund the insurer subsidies for two years, as well as the rest of this year, after Trump said he was going to cut them off. In exchange, states would get an easier waiver process so they don't have to follow all of the ACA coverage rules.

What Trump has said:

  • Yesterday, after meeting with the Greek prime minister: “it is a short-term solution so that we don't have this very dangerous little period — including dangerous periods for insurance companies, by the way ... For a period of one year, two years, we will have a very good solution. But we're going to have a great solution, ultimately, for health care."
  • Last night, in speech to the Heritage Foundation: "While I commend the bipartisan work done by Senators Alexander and Murray -- and I do commend it -- I continue to believe Congress must find a solution to the Obamacare mess instead of providing bailouts to insurance companies."
  • This morning on Twitter, after Axios event with Alexander: "I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co's who have made a fortune w/ O'Care."
  • This morning, before a meeting with Senate Finance Committee members: "If something can happen, that's fine. But I won't do anything to enrich the insurance companies."

What Sanders said this afternoon: "A good step in the right direction," but “it's not a full approach, and we want something that goes a little bit farther."

Who's against the deal: House Speaker Paul Ryan — which would make it hard to get the bill through the House, even if it gets through the Senate. Office of Management and Budget director Mick Mulvaney has also said the administration wouldn't support an Alexander-Murray bill without big concessions.

Who's for it: It's clearly in Democrats' interests to keep the ACA markets from falling apart, but there's also significant support among Senate Republicans for stabilizing the markets, Sen. John Thune told Caitlin Owens yesterday.

Go deeper: Mike Allen on Trump's improvisational style.

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Trump's gripes with ACA bill are his own fault, Schumer says

Minority Leader Chuck Schumer said President Trump doesn't know what's in the health care deal. Photo: Andrew Harnik/AP

The Trump administration rejected Democrats' proposals to prevent a windfall for insurance companies as part of the Senate's bipartisan health care bill, Minority Leader Chuck Schumer said today. He said Democrats wanted to delay the enrollment window so insurers could recalculate their premiums rather than sit on extra cash — but that the Trump administration nixed the idea.

Why it matters: Schumer essentially said that the administration opposed a policy that would have helped address the president's complaints about "insurer bailouts."

The issue: Insurance companies in most states have already finalized their premiums for 2018, and most of them are charging higher premiums because they assumed they wouldn't be receiving federal payments for the Affordable Care Act's cost-sharing reductions. The compromise bill from Sens. Lamar Alexander and Patty Murray would restore those payments — on top of the extra premium dollars insurers are already locked into.

What the bill does: Insurers that charged higher premiums because they assumed they wouldn't receive the CSR payments would have to return the extra premium revenues to consumers and the federal government.

  • Giving insurers time to recalculate new premiums, with the knowledge they would be receiving the CSR payments, would have made this "double dipping" prevention unnecessary.
  • "The money does not go to the insurance companies...we demanded it. Both sides," Schumer said.

How it happened: Schumer said Sen. Lamar Alexander, the GOP author of the bill, was fine with the idea personally but rejected it because of White House opposition. A senior GOP aide said that isn't true, calling the proposal to delay open enrollment "ridiculous" and saying that Alexander immediately rejected it.

  • "We're two weeks away from open season," the aide said, "and not passing anything this week or next week."