Mar 20, 2017

Axios Vitals

By Caitlin Owens
Caitlin Owens

Good morning ... Know what Obamacare is getting for its 7th birthday on Thursday? A repeal vote in the House, that's what! Happy birthday, Obamacare. Gonna be the worst birthday party ever. Brings back bad memories of when I lost at miniature golf on my 7th birthday, and then got repealed.

This is going to be one of those weeks where you really need help de-cluttering your news, and that's what we, on the Axios health care team, are trying to do. But if you think we're missing important stuff, please let us know. And keep checking the Axios health care news stream for all the latest, and sign up for our newsletters and breaking news alerts here.

The three big things to know for repeal week

Here's what you need to know as we head into the week of the House vote:

  • Republican leaders may be within striking distance of the 216 votes they need for Trumpcare to pass the House.
  • They're nowhere close to the votes they need in the Senate, thanks to conservatives and moderates turning against it for different reasons.
  • The one new change that seems almost certain to happen: The tax credits will be reworked to give more help to the low-income elderly.

There's still a long way to go in the House, but GOP leaders are a lot closer to nailing down the votes after President Trump struck a deal with the Republican Study Committee on Friday morning to win their support. (Caitlin Owens and Jonathan Swan give a rundown here of the Medicaid changes they've been promised.) Here's who to keep your eye on now:

  • Freedom Caucus members: Even after the Republican Study Committee got on board on Friday, the Freedom Caucus tweeted that it "still opposes the GOP replacement bill in its current form." CNN reports that the group's chairman, Rep. Mark Meadows, and Sens. Ted Cruz and Mike Lee met with top Trump aides at Mar-a-Lago this weekend to try to push the bill farther to the right.
  • Reality check: The Freedom Caucus is certainly capable of causing trouble for House Speaker Paul Ryan — they made life miserable for John Boehner. But how many would actually vote against a repeal bill when the time comes? You'll know the tide has turned if you start hearing "I don't like it but won't stand in the way" speeches.
  • Moderates: The Washington Post has a good look at what it calls the "sleeping giants," or the moderates who are appalled by the estimated coverage losses. Many are from states that expanded Medicaid, and don't like how the bill handles the end of the expansion.
  • Reality check: The GOP leaders are trying to win them over, as Jonathan Swan reported yesterday — but when was the last time a bill failed in the House because moderate Republicans all stood their ground against the leadership? It's not impossible, but it doesn't happen very often.

The bigger problem is in the Senate, where senators are more independent and less likely to fall in line than in the House. Sens. Ted Cruz and Susan Collins were on separate Sunday talk shows discussing how they can't support the bill, but from opposite ends of the spectrum: Cruz wants to knock out the Obamacare insurance regulations, while Collins is worried about lost coverage and Medicaid cuts. Try to figure out the formula that makes both happy.

Hospitals have a big labor problem coming up

Obamacare was good for health care jobs around the country, but especially for hospitals. Now, Bob Herman reports that they're going to have a problem on their hands if repeal happens: What are they going to do with all of those expensive new hires if millions of people lose health coverage? The hiring has already slowed down because of all of the uncertainty, and if they have fewer patients who can pay for their medical care, they might have to reduce their staffs through attrition — or layoffs. Read Bob's story here.

Don't spend a ton of time learning about "Phase 3"

I was all set to give you an in-depth look at all of the health care bills Republicans are lining up for "Phase 3" of Obamacare replacement — all the proposals they can't put in the budget "reconciliation" bill. Here's the list so far:

  • Competitive Health Insurance Reform Act of 2017 — eliminating the antitrust protection for insurance providers (House voting this week)
  • Small Business Health Fairness Act of 2017 — association health plans (House voting this week)
  • Medical malpractice reform (later this month)
  • Protecting self-insurance (later this month)
  • Selling health insurance across state lines (House Energy and Commerce subcommittee hearing coming soon)

There are substantive reasons to learn about the pros and cons and all of them. But here's the problem: All of them might be able to pass the House pretty easily, but then they'd all need Democratic votes to pass the Senate, since they'd need 60 votes.

So I asked around about whether any of them could get enough Democratic votes, and here's what a Senate Democratic leadership aide told me: "No they will not. We are happy to work with Republicans to improve health care but they have to drop repeal first. If they manage to pass a repeal bill, they're on their own. There won't be a phase 3."

Cruz actually laughed at the idea on CBS's "Face the Nation" yesterday when John Dickerson asked him about it. "That ain't going to happen," Cruz said, calling it "the sucker's bucket." So, moving along ....

Price is still a fan of Medicare balance billing

Steven Brill points out something for your radar: Price's long fight to let doctors charge more to Medicare patients could now be a big deal. Modern Healthcare reported that in his written responses to questions from the Senate Finance Committee considering his nomination for Health and Human Services secretary, Price didn't back down from his support for a change in the Medicare law that would allow doctors participating in the program to "balance bill" Medicare beneficiaries — meaning they could charge them more than the amount Medicare pays. (You can read the exchange here — it starts on page 8.)

Balance bills are often given to patients with private insurance, usually because they are using a doctor out of the insurance company's network. But the practice has always been banned for doctors treating Medicare patients. Under the change long advocated by Price, a former orthopedic surgeon, the doctors could have their cake and eat it, too: be in the Medicare network, but charge as much extra as they can to as many patients as they can.

Why it matters: Medicare, with about 55 million enrollees, protects about twice the number of Americans who are enrolled through the Obamacare exchanges and the expansion of Medicaid.

While you were weekending ...
  • House Rules Committee chairman Pete Sessions faced chants of "Vote him out!" at a town hall meeting in Richardson, Texas, as he talked about the Obamacare repeal effort.
  • Sen. Rand Paul, on ABC's "This Week," predicting the House GOP bill won't pass: "I believe that the real negotiation begins when we stop them."
  • Ryan, on Fox News Sunday, on Trump's proposed cuts to the National Institutes of Health: "NIH is something that's particularly popular in Congress. We just passed the Cures Act just this last December to increase spending in the NIH."
  • Collins on NBC's "Meet the Press," on Trump's NIH cuts: "If we're serious about reducing health care costs, the last thing that we should be doing is cutting the budget for biomedical research."
  • Price, on ABC's "This Week," on ProPublica's bombshell report that U.S. Attorney Preet Bharara was investigating Price's stock trades before he was fired: "I have -- know nothing about that whatsoever."
  • The New York Times looks at how the GOP is confronting the reality that a lot of blue-collar Trump voters depend on government medical care.
  • The Center for American Progress has a district-by-district breakdown of how many people would lose coverage under the GOP bill, based on the Congressional Budget Office estimates.
  • Avik Roy writes that the GOP bill's premium increases for the elderly could be eliminated by means testing the tax credits and adding a standard deduction.

New on Twitter: Centers for Medicare and Medicaid Services administrator Seema Verma (@SeemaCMS). And if you're not following Tom Price's official account yet, it's @SecPriceMD.

Why Medicaid work requirements won't work

Some think tank is apparently warning that work requirements for Medicaid — the latest thing Republicans are about to add to the Obamacare replacement bill — won't work because "making cash assistance or food stamps contingent on work participation is one issue, denying medical care to sick, poor people is another matter."

Just gonna check and see who wrote that — guessing it's the Center for American Progress or some other lefty think tank that would never...OMG IT'S THE HERITAGE FOUNDATION. Here's what senior research fellow Robert Rector wrote: It's likely to be optional, so most governors would ignore it; the rule would be "almost impossible to administer and enforce;" and, no one's really going to deny medical care to someone who didn't do their work assignments.

Rector isn't really against work requirements in principle — he just thinks they should be applied to food stamps, which would be easier to enforce and covers a lot of the same population. But it will be interesting to see if any Republicans grapple with the practical problems when the Medicaid part of the bill is being rewritten.

Caitlin Owens

What we're watching today: Trump rally in Louisville, Kentucky to build support for the GOP bill, 7:40 p.m. Eastern. Also, Trump meets with Ryan, Price, and Zeke Emanuel, 11:30 a.m. Eastern.

What we're watching this week: House Rules Committee takes up the Obamacare replacement package, probably Wednesday ... and the big House vote, Thursday. The House also votes on bills to eliminate the antitrust protection for insurance providers and to create association health plans. Also, Senate HELP Committee will hold a hearing on reauthorizing the Food and Drug Administration's user fee agreements, Tuesday.

Thanks, and let me know what you'll be drinking on repeal night: david@axios.com.