Axios

Republican Rep. Doug Collins of Georgia does not like the pharmacy benefit management industry, and he and others in Congress are ready and willing to regulate those companies, which serve as middlemen in the drug supply chain. "There's several things that are going to be coming up," Collins told Axios Tuesday.

I truly believe the PBM industry is one of the most detrimental pieces of health care.

A popular GOP idea — allowing insurers to charge older people more compared to Obamacare — would increase federal spending and lead to double-digit premium increases for older adults on the individual market, a new AARP-sponsored report finds. It'd also cause 18,000 to lose coverage.

Insurers have criticized Obamacare's rule that only allows plans to charge older people three times the amount they charge young people. They've recently been pushing to change the ratio from 3:1 to 5:1, and the House Energy and Commerce Committee held a hearing on a bill doing so last week.

Why this matters: The AARP is a powerful lobbying force. If it campaigns against raising the ratio, that could easily kill one of the main Obamacare replacement policies the GOP is currently putting forward.

Key findings:

• Premiums for adults 60 and older would increase by 22 percent.
• Premiums for adults 50-59 would increase by 13 percent.
• Young adults 20-29 would see a 15 percent reduction in their premiums.
• Enrollment would increase by only 2 percent.

More and more it's looking like the Trump administration might not be able to get everything done in its first 100 days.

• Healthcare: GOP Hill sources told Axios that putting all the "replace" parts of health reform in place could take years. In his interview with Bill O'Reilly, which Fox News is spacing out over three nights, Trump hinted that a new healthcare law might not be rolled out within the year. As the NYTimes points out, the president's admission of replacing Obamacare is sure to be a serious disappointment to Trump's most fervent supporters.
• Tax Reform: When asked whether Americans can expect tax cuts by the end of 2017, Trump told O'Reilly, "I think so, yes. And I think that before the end of the year I would like to say yes."
• Infrastructure wish lists: In a process that began during the transition, governors from at least 44 states this week will send the administration a wish list of 300 infrastructure projects, ranging from dredging to light rail to safe water to Interstate widening. McClatchy has 20 examples.
• Risks of Trump infrastructure bank: AP's Joan Lowy and David Lieb describe how economists and transportation experts are concerned that the government may end up rewarding investors in projects that would have been built without credits.

So far, most of the conservative groups that have been pushing Obamacare repeal the hardest — like Americans for Prosperity and Heritage Action — have pulled some punches as the effort has slowed. Even as Republicans' internal disagreements have become more obvious, they haven't hit hard against statements like Sen. Lamar Alexander's talk of "repair" rather than repeal. Now, they're going to start pushing Congress to get on with it.

"It's time for Congress to put out language — actual, specific language" for repeal and replacement bills, Americans for Prosperity president Tim Phillips told me. He didn't sound worried about President Trump's comments to Bill O'Reilly Sunday about the repeal work possibly continuing into next year: "We're more focused on getting language."

Top Republicans insist they're still on the case, and that they're still united in their goal of repealing and replacing the law, as Senate Finance Committee chairman Orrin Hatch said in a floor speech yesterday. But the lack of movement in the committees has become pretty obvious. Here's the evidence House Speaker Paul Ryan's office cited yesterday to prove that Congress is doing things on repeal:

• The House Energy and Commerce health subcommittee is working on two Medicaid bills this morning: one to make it harder for wealthy couples to get Medicaid, the other to make sure it's not spending money on lottery winners.
• The House Small Business Committee is holding a hearing.
• Tom Price may be confirmed later this week.

TeamHealth, a physician staffing firm, has agreed to pay the federal government $60 million to resolve allegations its physicians fraudulently billed Medicare and Medicaid.

The primary issue is a process called upcoding. It's when physicians submit bills to insurers for more expensive care than was actually delivered. For example, instead of billing for a less pricey medical code that covers 15 minutes of hospital bedside care, physicians would submit the more expensive code for 35 minutes, even though they only spent 15 minutes with the patient. In this case, it was hospital-based doctors from IPC Healthcare, which TeamHealth had acquired.

Why this matters: Allegations of upcoding have been rampant in the industry, as the Center for Public Integrity has reported. This rather large settlement shows the government is paying attention. But in reality, the penalty is a slap on the wrist for TeamHealth, which recently was taken private by Blackstone and was on pace for $4.5 billion of revenue in 2016.

Drug spending increased 3.8% in 2016 for employers and health insurers that hired Express Scripts to manage drug costs for their commercially insured members, according to an annual report from the pharmacy benefits manager.

The big takeaway: Express Scripts cheered the findings as evidence their negotiations with drug companies and pharmacies kept drug spending lower than people might expect. The report is also being used as a way to push back against drug companies that have blamed pharmacy benefits managers for the drug pricing problems. "We don't do anything to set prices for the drug manufacturers. They do," Dr. Glen Stettin, chief innovation officer at Express Scripts, told Axios.

Yes, but: This report did not reveal anything about the rebates Express Scripts collects, nor did it touch Medicare drug spending. A recent federal government report showed that Medicare Part D rebates to middlemen were eating up a much larger chunk of total drug spending. Stettin said Express Scripts would release its own Medicare report soon, and it would disprove the "fallacy of rebates driving up the cost of medications."

Tom Price, who is expected be confirmed as Secretary of Health and Human Services this week, is expected to immediately start picking apart Obamacare legislation once approved by the Senate. Here are the things he can do, per Politico, without waiting for Congress.

1. Loosen Obamacare's benefit rules and give insurers more leeway in determining which healthcare benefits they'll pay for.
2. Target the contraception coverage mandate by halting enforcement of the law. He could go even further, targeting the individual mandate itself.
3. Tighten the enrollment rules and ramp up monitoring of Obamacare enrollees.

Once confirmed, Price will have plenty of room to singlehandedly shift healthcare toward a free-market system. Doing so will show that Price is taking the reins on unraveling Obamacare legislation, and in turn giving stonewalled congressional Republicans more clarity about what to do next.

Obamacare didn't kill the health insurance industry, and whatever comes after won't kill it either — as long as it can scrape through the next few years.

There's been a lot of nervous talk from insurance CEOs about how they need to know what's happening next. That's a real problem, as Republicans struggle to figure out what they're actually going to do about Obamacare. But the bigger picture looks much better.

Wall Street analysts are betting health insurers — who have mostly thrived under Obamacare despite their recent setbacks — will become even stronger under Donald Trump and Republicans, who plan to shred regulations and push more taxpayer-funded programs into private control.