Axios Vitals

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September 27, 2017

Good morning ... Many thanks to all of you who kept up with Vitals, or perhaps signed up for the first time, throughout the Graham-Cassidy debate. I loved getting all your thoughts, story ideas and suggestions, and hope you'll keep them coming.

The Senate’s ACA debate is far from over

Repeal-and-replace is dead, at least for now. But congressional Republicans nevertheless have some very big decisions to make about the Affordable Care Act, important provisions of which could quickly end up right back onto the bargaining table.

Bipartisan stabilization: Sens. Lamar Alexander and Patty Murray said they intend to restart their search for a bipartisan bill that would stabilize the ACA's insurance markets, probably through some combination of funding guarantees for insurers and regulatory flexibility for states.

  • GOP leaders poured cold water on those talks while Graham-Cassidy was still in play, but at least one member of leadership, Sen. John Thune, sounded open to a bipartisan package after Graham-Cassidy failed.
  • "There are going to be some things that in the near term may have to be done to stabilize markets, and that kind of thing can be done in a bipartisan way…I think if they can produce something, more power to them. I'm not optimistic about that," Thune told reporters.

Decisions about tax reform: A not-insignificant contingent of Senate Republicans wants to take another crack at health care in the same bill they're using for tax reform — potentially combining the two extremely hard jobs into one even harder undertaking.

  • GOP leaders are against combining health care and tax reform, fearing it would kill both. But that doesn't necessarily mean they can stop it if the idea catches on.

ACA taxes: Even if health care and tax reform aren't formally combined, there's already been some talk of pulling some of the ACA's taxes into the broader tax reform effort.

  • There have already been talks about trying to repeal the individual mandate as part of tax reform.

One last thing: Part of the Alexander-Murray talks involve a commitment to keep paying the ACA's cost-sharing reduction subsidies, or CSRs, which the Trump administration has been paying one month at a time. Check out this quote from Thune: "The White House, the administration, obviously has the authority to extend the CSRs."

Flashback: You may recall that Republicans took the opposite view during the Obama administration. They sued to stop the White House from extending the CSRs, saying it was unconstitutional, and they won.

Deadline day for the exchanges

Insurers have to decide today whether they're in or out of the ACA's exchanges next year. Axios' Bob Herman isn't expecting a ton of last-minute changes — the companies that have said they're in will probably stay in.

  • Who's in: Regional and safety-net insurers; insurers tied to hospital systems; and smaller community-based plans.
  • Who's out: Aetna, Humana and UnitedHealth Group — some of the industry's biggest players.
  • Who to watch: Anthem, which has substantially pared back its exchange presence.

Lay of the land: All of the "bare counties" have been filled (unless new ones open up today). Here's where things stand, as of the last official update from the Department of Health and Human Services:

  • Roughly 70% of exchange enrollees will have two or more plans to choose from.
  • The remaining 30% live in areas where only one insurer is participating next year.

Graham-Cassidy: winners and losers


  • Democrats: All of these bills died because of internal Republican divisions, but there's no denying that this whole process has helped organize and energize Democrats from across the party's ideological spectrum.
  • Alexander (maybe): Alexander has been beating the drum on ACA stabilization for months. We'll see what happens in his committee, but there seems to be a good chance he'll get closer to success than the repeal-and-replace effort did.
  • Medicaid providers and disability advocates: Medicaid's allies came out in force throughout the entire summer. Conventional political wisdom used to hold that Medicaid, unlike Medicare, would be relatively easy to cut. It might be time to rethink that.


  • Bill Cassidy: One of the most vexing mysteries of 2017 is why the senator invented the "Jimmy Kimmel test" in the first place. He didn't even walk into a trap, so much as he set one for himself.
  • Dean Heller: He flip-flopped from an ardent opponent of steep Medicaid cuts to the cosponsor of steep Medicaid cuts. Not a great way to earn credibility with any of the people who were pushing the senator in either direction.
  • Mitch McConnell: The Senate majority leader will be fine, but there's really no way to look at this other than as a failure to make good on a campaign promise Republicans have been making for four cycles.

Congress' other Sept. 30 deadline

Federal funding for the Children's Health Insurance Program is set to expire at the end of the month.

What's happening: Earlier this month, Sens. Orrin Hatch and Ron Wyden, the chairman and top Democrat on the Finance Committee, reached a deal to extend the program for five years while gradually phasing out a funding bump from the ACA.

Yes, but: The path forward for passing that agreement hasn't yet been determined, though most states have enough CHIP funding on hand to carry them past Sept. 30.

  • Congress also needs to pass a handful of Medicare-related "extenders" by the end of the month. At least for now, they're attached to the House's bill to reauthorize the Federal Aviation Administration, which also needs to pass this week.

Price's private jet problems take off

HHS secretary Tom Price sometimes tacked some personal business — like visiting his son or his property — onto the official trips for which he chartered private jets at the taxpayers' expense, Politico reported last night. Politico has identified 26 times Price chartered a private jet for official travel since taking over at HHS, for a total of more than $400,000.

  • Top Democrats on the House Appropriations Committee — Reps. Nita Lowey and Rosa DeLauro — have requested a full accounting of Price's private-jet travel.
  • And President Obama's first HHS secretary, Kathleen Sebelius, told Bloomberg that Price's use of chartered aircraft was "stunning." She said she only flew on a private plane once — to reach some far-flung villages in Alaska.

Why it matters: In any other year, this story would be everywhere. And the HHS inspector general is also conducting an investigation. Especially with the more immediate Graham-Cassidy furor off the table, don't expect this story to, ahem, fly under the radar.

What we're watching today: Insurers' contract decisions.

What we're watching this week: The House's progress on Medicare extenders

It's over! We're free! For now! What are you going to do with yourself now that repeal-and-replace isn't taking up every minute of every day? I'm taking suggestions: [email protected]