Axios

Iowa officials have filed a far-reaching waiver that would massively reform pieces of the Affordable Care Act in the state, the Wall Street Journal reports. This could pave the way for other states to file and implement ambitious changes to the health care law without having to wait for Congress to act.

What the waiver does:

• Creates a market with only one insurance plan.
• Makes premium subsidies flat payments tied to age and income.
• Eliminates subsidies that help low-income people with out-of-pocket costs.
• Requires consumers to prove they've maintained continuous coverage.
• Establishes a reinsurance program to help insurers with expensive enrollees.

Context: The ACA is not working well in Iowa (partially due to the state's own implementation decisions). Earlier this year, there was set to be no insurance option for 2018 in most of the state until Medica stepped in. That averted disaster, but means there is no competition in most counties. If the waiver is approved, Wellmark Blue Cross and Blue Shield will participate in the marketplace.

Medicare is the largest purchaser of health care services in the country, and over the past decade, there's been a gradual change in how those taxpayer dollars are spent, according to data from the independent Medicare Payment Advisory Commission.

Since 2006, Medicare is shifting money from physician practices and inpatient hospitals (where a person needs an overnight stay), and toward private health insurers and other companies that run the Medicare Advantage and Part D prescription drug programs. Spending also has increased in outpatient settings.

A new report in the New York Times revealed that President Trump and Senate Majority Leader Mitch McConnell haven't spoken in weeks — and McConnell has been telling people behind the scenes that Trump is "unwilling to learn the basics of governing" as his administration approaches the point of no return.

• The flash point: The Senate's failure to pass health care reform led to a "profane shouting match" of a phone call between McConnell and Trump. It also alienated other GOP senators, as West Virginia Sen. Shelley Moore Capito was refused a seat on Air Force One after refusing to commit to a repeal vote.
• Why it matters: The GOP's hope for achieving meaningful reform —involving health care, taxes, or infrastructure — rests on Trump keeping an open line of communication with congressional leaders. The more that he poisons that well, the more he risks kneecapping his own agenda.

HELP Committee Chairman Lamar Alexander and Ranking Member Patty Murray today announced the first two of four September hearings on the individual market. The first hearing on Sept. 6 will focus on testimony from state insurance commissioners, and the second hearing on Sept. 7 will focus on governors' testimony.

Why it matters: This is a step in their effort to craft a short-term stabilization package after the GOP's partisan health care effort failed.

What's likely to be in the package:

• Funding for the Affordable Care Act's insurer subsidies, which are currently being paid by the Trump administration but which the president has threatened to cut off.
• A more flexible state innovation waiver, although the details on this are unclear, as is the number of years insurer subsidies would be funded.