Dec 21, 2017

Axios Vitals

Good morning ... Quick fact check here: Congress has not "essentially repealed Obamacare," as President Trump claimed yesterday, by repealing the individual mandate. The law will likely be significantly weaker now, but it is very much still on the books.

Honey, I Shrunk Obamacare

Years of sustained political attacks and self-inflicted wounds have left the Affordable Care Act a lot smaller than anyone — from its drafters to its harshest critics — ever anticipated. It doesn't cover nearly as many people as Democrats hoped, and its new federal controls have turned out far weaker than Republicans feared.

Why it matters: Although a diminished ACA might seem like a clear victory for the law's opponents, the law as it exists today is in many ways more liberal than the one Democrats passed in 2010. Its benefits are more concentrated on a smaller group of sicker, poorer people, while the middle class has gotten an increasingly bad deal as the law's scope has shrunk.

What happened: Think of the ACA's core coverage provisions like a comet with a tail. As the ACA has evolved, the tail — the benefits that extend further up the income ladder — keeps taking the biggest hits. The parts of the ACA that offer comprehensive benefits to poor people are safe. Its efforts to build a more competitive market for the middle class are the parts that keep failing.

Go deeper: Read my full story in the Axios stream.

​Collins isn't getting her health care votes this year

Hope you're sitting down for this stunning development: It appears that Congress will not be attending to some relatively simple priorities in a timely fashion.

CHIP: Congress has not yet renewed funding for the Children's Health Insurance Program, which expired Sept. 30.

  • As Axios previously reported, renewing federal funding for CHIP will likely slip into January.
  • Roughly 2 million children could lose their CHIP coverage in January if Congress doesn't act this week, according to a new analysis from health policy experts at Georgetown.

ACA stabilization bills: Sen. Susan Collins has already voted "yes" on the tax bill, but the health care votes she was promised in exchange won't be happening this year, my colleague Caitlin Owens reports.

  • Senate Majority Leader Mitch McConnell promised votes on two measures — one to restart the cost-sharing payments Trump cut off; and another to establish a new reinsurance fund to help insurers cover their most expensive claims.
  • McConnell cannot promise that those bills will actually pass, and both could run into some opposition — from Democrats on the cost-sharing payments and House Republicans on reinsurance.

The bottom line: All of this has slipped because it's all tied together with a bill to fund the federal government, and that has slipped, too. The goal has always been to tackle CHIP and health care (and perhaps some other Democratic priorities) as part of that spending bill, but Congress has been keeping the government open two weeks at a time as it tries to negotiate the actual bill, including these add-ons.

​We are dying sooner

The Centers for Disease Control and Prevention put out its latest life expectancy and death rate numbers this morning, and the figures are pretty grim, my colleague Bob Herman reports.

By the numbers:

  • "Life expectancy declined in the U.S. for the second consecutive year in 2016" from 78.7 years to 78.6 years, the CDC said. "This was the first time life expectancy in the U.S. has declined two years in a row since … 1962 and 1963."
  • One major reason: the opioid epidemic. The death rate from drug overdoses was 21% higher in 2016 than in 2015. It's affecting people of all ages, and no state had a higher drug overdose death rate than West Virginia (52 deaths per 100,000 people, or 2.5 times higher than the national rate).
  • Unintentional injuries — like a car crash or a drug overdose — are now the third-leading cause of death.
  • Heart disease and cancer remain the leading killers, but death rates from those diseases actually declined from 2015 to 2016.
So about that medical device tax

The GOP tax bill didn't include a repeal or extended suspension of the ACA's medical device tax, and it's looking like Congress now won't deal with ACA taxes in the year-end spending bill — even though the industry was banking on it.

What's next: Look for some extreme strong-arming from medical device lobbyists. The Advanced Medical Technology Association sent a letter to Trump yesterday demanding that Congress delay the tax before the holidays, instead of doing it retroactively in January.

  • At a minimum, AdvaMed CEO Scott Whitaker wrote, Trump should permit the IRS to waive the requirement that device companies have to make their tax payments every two weeks.

Between the lines: Some medical device companies apparently didn't bother preparing for the return of the excise tax because they assumed their lobbyists would win.

Are we headed for a government shutdown? What do you think? Let me know: baker@axios.com.