Axios Vitals

A briefcase with a red cross on the front.

Good morning ... The Senate's back in town after a mixed bag of recess town-halls, and ready for a decidedly even more mixed bag of tough policy decisions.

Seriously, Senate, it's decision time

The Senate is coming back from recess, and Republicans are going to look at what GOP leaders and staffers have put together on the health care bill. But it's not like there's going to be an actual bill to read. Instead, it's going to be more like a collection of ideas and a list of the big decisions senators still have to make, with a list of options and a discussion of the tradeoffs with each one, people close to the process tell us.

They're focusing on four "buckets" of issues:

  • Medicaid
  • Repeal of the Affordable Care Act taxes
  • Tax credits
  • Premiums

What they still have to decide: There are basic issues that the senators still have to pin down, like how slowly to phase out the ACA's Medicaid expansion and what's the best growth rate if they limit federal Medicaid funding. And they want to prevent more huge rate increases, but that probably requires a decision on whether Congress should fund the ACA's cost-sharing subsidies.

What's still on the table: Auto-enrollment is still very much in the mix, a GOP aide tells Caitlin Owens. That's where everyone would be automatically enrolled into a basic health plan, though they could opt out or choose a different plan. (Outside conservative groups are trying to kill the idea.)

Unlikely but not dead: Don't expect a tax on employer health benefits — floated in the Wall Street Journal last week — to be in the bill. At best, it's a source of sharp disagreement in the GOP ranks. One source tells us it's definitely off the table and isn't even a part of the discussions — but another says there's enough interest among GOP senators that it can't be ruled out.

Pessimism update

In the last week of their recess, a handful of GOP senators poured some cold water on ambitious predictions about the pace of their party's health-care effort.

  • Jeff Flake, who's up for reelection next year in a state that expanded Medicaid: "There are some still saying that we'll vote before the August break. I have a hard time believing that."
  • Richard Burr, who's been a health-policy player in the past: "I don't see a comprehensive health care plan this year."
  • Ron Johnson, who's already advocated a more short-term bill to stabilize the existing system: "To me, this may be a two-part process. I would admit that's probably a minority view in the Republican Senate right now."

Blue Cross Blue Shield plans are doing better under ACA

In fact, they're doing better than they were at the same time last year, Bob Herman reports this morning. He went through the first quarter reports of all of the Blue Cross Blue Shield plans in states where they're the last Affordable Care Act insurer standing: Alabama, Alaska, Oklahoma, South Carolina and Wyoming. Read the story if you want the exact results, but here's the gist:

  • First quarter 2016: Lost money (except Wyoming)
  • First quarter 2017: Made money

Why it matters: Bob has already reported on how well the publicly traded health insurance companies are doing this year, but the Blues plans are especially significant because they're the insurers of last resort. It doesn't mean everything has been going great for them under the ACA. But it does mean things are looking better this year — and it means those markets aren't imploding.

Silicon Valley's health care adventures

Silicon Valley is learning the hard way that health care is nowhere near as easy to disrupt as hotels, taxis or food delivery. Why? Because it's not a straightforward consumer good: It's a complex web that includes patients, doctors, hospitals, payers and massive federal bureaucracies, all with different goals and incentives. As one health care/tech company official put it to to CNBC: "It's not like a car where if you drive, you drive … No one uses the health system in the same way."

And that means Silicon Valley has pulled back to the edges of the health care system, where there's a chance at big profits—but not necessarily big changes to the heart of the system so many Americans simultaneously rely on and hate.

While you were weekending ...

  • President Trump is hosting a fundraiser next weekend for Rep. Tom MacArthur, the author of the amendment that allowed the House health care bill to pass, the Philadelphia Inquirer reports.
  • The New York Times looks at Democrats' shift toward embracing single-payer health care — largely because of Bernie Sanders and their own dissatisfaction with the Affordable Care Act.
  • The Times also breaks down Sen. Susan Collins' pivotal role in the health-care debate, including her concessions about the ACA's value as well as some of the changes she'd like to see made.
  • The Wall Street Journal took a trip to Iowa — Ground Zero for Republicans' argument that the ACA is failing— and found some big divisions among voters.
  • Nurse practitioners are in growing demand as more states give patients direct access to them for primary care, per Forbes.
  • Blue Cross and Blue Shield of Illinois is getting its first review in 27 years for compliance with state consumer protection laws, the Chicago Tribune reports.

What we're watching this week: Senate Republicans will either decide which health care options they like, or they won't. Health and Human Services secretary Tom Price testifies on the HHS budget proposal on Thursday — Senate Finance Committee in the morning, House Ways and Means Committee in the afternoon.

Also, the investment bank Jefferies holds its global health care conference in New York City, Tuesday through Friday. Facebook holds a health summit on Tuesday for pharmaceutical marketers, per CNBC.

Go start your week, and let us know what you're hearing: [email protected], [email protected]