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Good morning ... Philly readers: Former Vice President Joe Biden and Dr. Jill Biden, along with Sean Parker, are joining our Mike Allen Wednesday to discuss the future of cancer care, and you're invited. Mike will also explore this topic with Celgene CEO Mark Alles, cancer survivor and advocate Stefanie Joho, and Dr. Elizabeth Jaffee, deputy director of the Kimmel Cancer Center at Johns Hopkins. RSVP here.

Mental health: not just about mass shootings

"I think that mental health is your problem here," President Trump said yesterday, in response to the shooting that left 26 people dead at First Baptist Church in Sutherland Springs, Texas. It's become an increasingly common refrain in the wake of mass shootings. And mental-health advocates are getting a little tired of this pattern.

"It really hurts a lot because one of the things we always have said in the aftermath of these kinds of tragedies is, you cannot equate mental illness with violence," said Paul Gionfriddo, the CEO of Mental Health America.

  • Gionfriddo said the response to this shooting has been particularly frustrating because, while mental illness isn't a predictor of violence, a history of violence is — and the shooter, Devin Kelly, reportedly had a history of domestic violence.
  • While "mental health" is usually mentioned in these situations — usually vaguely, and as an alternative to gun control — Congress has rarely gone on to actually improve the mental health system.
  • "If you really want to think about what these violent actions mean in terms of mental health and mental health services, you've got to look at the victims," he said. People wounded in mass shootings, and victims' families, emerge deeply traumatized. "These wounds will not heal on their own."

But it might be getting better. I asked Gionfriddo how frustrating it is to see politicians, and much of the public, associate mental illness so closely with mass shootings. His answer was both optimistic and profoundly depressing: More people have started to ask that question, he said, in the wake of more recent mass shootings.

  • Two or three years ago, he said, hardly anyone pushed back to mention the millions of people who suffer from mental illness but are not violent. But he's seen more people make that point more recently.
  • "I realize I've got to say this 100 times before some people will hear it the first time," Gionfriddo told me. "I don't mind saying it 100 times. I'll say it 1,000 times, 10,000 times."
Medicaid on the ballot

It's Election Day — and there's a lot at stake for the Affordable Care Act's Medicaid expansion.

Voters in Maine will have a chance to weigh in directly, via a first-in-the-nation ballot initiative on whether to expand Medicaid. It stands a good chance of passing — but even if it does, an actual Medicaid expansion in the state could be more than a year away.

  • The state legislature has already voted six times to expand Medicaid; Gov. Paul LePage has vetoed each one. Today's referendum was initially seen as a way to work around LePage's steadfast opposition.
  • But even if today's referendum passes, LePage's administration may well drag its feet until the governor is term-limited out of office next year, according to Mitchell Stein, a Maine consumer advocate who supports expansion. LePage's successor would then have to implement the expansion.
  • The symbolism of a win would still be significant. National advocacy groups are looking for a victory in Maine to help set the stage for similar ballot initiatives in other non-expansion states. And it'd be a morale boost for the ACA's advocates, at a time when the law is under attack. "There are positives on an emotional level," Stein told me.

Medicaid expansion is also in the balance in Virginia. Outgoing Gov. Terry McAuliffe tried to expand the program, but was rebuffed by Republicans in the state legislature. But Democrats have a good shot at picking up seats in the statehouse — if they pick up enough, Medicaid expansion could advance in Virginia even before it does in Maine.

Why it matters: The ACA's Medicaid expansion would cover an estimated 400,000 people in Virginia and 80,000 people in Maine.

Go deeper: The Trump administration isn't doing much to boost enrollment in the ACA's exchanges, but a raft of open governors' races next year present an opening for millions more people to gain Medicaid coverage — making the law's repeal even more politically difficult.

ACA enrollment is … up?

More than 200,000 people selected plans on the first day of ACA enrollment, The Hill reports. That would roughly double the number of first-day sign-ups during the last open enrollment period.

What we don't know: How many of these consumers were renewing their coverage versus signing up for the first time. Traditionally, the biggest surge in new sign-ups has come around deadlines at the end of the enrollment period.

Tax overhaul won't tackle ACA fees on devices and insurers

Lobbying Christmas will have to wait until actual Christmas for the insurance and medical device industries. House Ways and Means chairman Kevin Brady said yesterday that Republicans' tax overhaul won't include steps to repeal or delay taxes the ACA imposed on those industries.

Instead, GOP leaders are working with Democrats on "temporary and targeted relief from many of these taxes to be acted on in the House before the end of the year," Brady said in a statement.

  • Be smart: The giant legislative package awaiting Congress in December has always been the best shot to get these taxes repealed or — more likely — delayed.

The big question: The new tax amendment Brady introduced last night does not include repealing the ACA's individual mandate, but Brady didn't mention that policy as he listed ACA-related items that are definitely off the table.

  • The Washington Examiner reported yesterday that Trump has prepared an executive order to substantially weaken the mandate, but is holding off in the hopes Congress will fully repeal the coverage requirement as part of its tax overhaul.
  • Including anything health care-related in the tax bill remains a risky strategy.
Blues in the black

Blue Cross Blue Shield health insurance companies have more than quintupled their net profits in the first half of this year compared with the same six months of 2016, according to an analysis of financial records by Fitch Ratings.

The bottom line: Why are profits still growing for the Blues? The answers, from my colleague Bob Herman: They raised premiums a lot, people are not going to the doctor or hospital as much, and the federal government modified some enrollment policies to the benefit of insurers.

  • What was true before is still true now: Most health insurers are not losing their shirts on the ACA's individual marketplaces (although next year could be different depending on what happens to the law's cost-sharing subsidies).

What we're watching today: Election results in Maine and Virginia.

What we're watching this week: House Energy and Commerce health subcommittee hearing Wednesday on "MACRA and Alternative Payment Models: Developing Options for Value-based Care."

Get in touch: I welcome your tips, comments and questions: baker@axios.com.