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Sens. Lamar Alexander and Patty Murray are trying to find an ACA compromise, (AP Photo/Alex Brandon, File)

Senate HELP Committee Chairman Lamar Alexander is trying to thread a very thin needle as he searches for a bipartisan bill stabilizing the Affordable Care Act's insurance markets. He's under pressure from all sides, but almost everyone agrees: If anyone is going to figure out how to solve this, it's him.

  • "Lamar is the perfect person to be in the position that he's in," Sen. Jerry Moran told me.

Yes, but: As Sen. Roy Blunt told me, "He's very capable and he's good at trying to find a rational argument on how to get something done. But this is a hard assignment, so we'll see how he and Sen. [Patty] Murray do."

Alexander has tried to carve out a narrow middle ground in a debate that has never really had one. Here's why it's so hard, and where the competing pressures are coming from:

  • The right: Several Republicans, including Finance Committee Chairman Orrin Hatch, quickly criticized the prospect of funding the ACA's cost-sharing subsidies as an "Obamacare bailout." Republicans are not going to readily vote to prop up a law they've spent years attacking, unless they get some real concessions. "Trying to get people to think about this outside of just the collapsing failure that many of us see in Obamacare is hard to do. And I think to get very many votes on the Republican side, you'd have to have a bill that arguably creates a lot more flexibility for governors and states," Blunt said.
  • The left: It's easy for Democrats to support funding the cost-sharing subsidies. But Alexander must convince them to get on board with more flexibility to the states — which and that would likely mean softening some of the ACA's insurance regulations, which Democrats don't want to do.
  • The real world: Insurers have proposed double-digit premium hikes; dozens of counties might not have any insurance plans available next year; and many more counties will only have one insurer. If Congress doesn't act, real people will get hurt."I don't think the question is what kind of challenge you face doing it. I think if you do nothing…you have a mad electorate who's mad at us not doing anything. I don't think we have any option," Sen. Johnny Isakson told me.
  • The clock: Insurers must decide by Sept. 27 whether to participate in the exchanges next year. That leaves Alexander very little time to act.

What Alexander says: "If it's balanced, I think I can persuade enough Republicans to support it. This is the kind of proposal where it will have to get a good number of Democrats and a good number of Republicans. It's not like it'll be one-sided."

The strategy: Alexander and Sen. Patty Murray, the top Democrat on HELP, have kept the discussion narrow, and brought in senators outside their committee at the beginning of the process. One of those senators, Sen. Angus King, said Alexander and Murray have handled this difficult task "just the right way."

  • "Lamar's really smart, really smart, he has great people around him, he has a great demeanor about him, and he has a great partner in Patty Murray," Sen. Tom Carper said.

Go deeper

Updated 18 mins ago - Health

Massage, facial, pedicure... intravenous drip?

A salon on the Upper East Side of New York that offers IV drip therapies. Photo: Jennifer A. Kingson/Axios

IV drips — the kind you might get if you're rushed to the hospital — are trending as a spa treatment, thanks in part to endorsements by celebrities like Kim Kardashian and Madonna.

Why it matters: Like other "wellness" trends with a whiff of medical imprimatur, IV nutrient drips can be harmless or mildly restorative — or go awry, particularly in the wrong hands.

U.S. sounds alarm on Ukraine

Conscripts line up at a Russian railway station yesterday before departing for Army service. Photo: Sergei Malgavko/TASS via Getty Images

The Biden administration is "deeply concerned" by new intelligence — detailed for Axios and other outlets — showing Russia stepping up preparations to invade Ukraine as soon as early 2022.

Why it matters: Most of this was known from public sources and satellite imagery, but the administration is sending a stronger signal by releasing specific details from the intelligence community.

Felix Salmon, author of Capital
2 hours ago - Economy & Business

Philanthropy in the age of crypto

Illustration: Annelise Capossela/Axios

The best charities are increasingly effective. That's the clear message sent by Open Philanthropy, the think tank that doubles as the grant-making vehicle for Facebook co-founder Dustin Moskovitz and his wife Cari Tuna.

Why it matters: With tech and crypto wealth becoming a fast-growing part of the philanthropic pie, there's more of an emphasis than ever on effectiveness — what the newly-divorced Melinda French Gates, in her recent Giving Pledge update, characterizes as giving as "impactfully as possible."