Axios Vitals

A briefcase with a red cross on the front.

Good morning ... The Senate is barreling toward a big, party-line health care vote, even as a special election for a once-safe seat has turned into a referendum on that health care plan. Welcome to the latest and decidedly least fun "Back to the Future" sequel.

The Senate is (still) planning to vote next week

Details about what's in the Senate bill are slowly starting to leak out, along with details about the process. Yes, Majority Leader Mitch McConnell still plans to hold a vote before the July 4th recess, which means things are about to start happening extremely quickly.

Timeline: We learned last night that GOP senators (or at least some of them) are being advised that they'll get a summary, legislative text, and preliminary score of the bill before they leave town Thursday evening. Thursday's lunch could get very nitty-gritty on policy details, one aide said. But it's also important to note that in a process as chaotic as this, plans can change quickly.

As the Wall Street Journal reported last night, a Congressional Budget Office score is expected early next week.

Medicaid portion: Here's what Caitlin Owens has heard about this part of the bill:

It would keep the growth rate for Medicaid per-person funding caps that is in the House bill, but only until 2025. The growth rate would then be reduced — from a metric pegged to medical inflation to one pegged to regular old inflation.The Medicaid expansion would have a three-year glide path down to a state's traditional funding level (as opposed to the higher Affordable Care Act match rate) beginning in 2020. This is somewhat of a win for moderates compared to the House bill, although they'd been pushing for a seven-year transition.States would be able to pick the base spending amount for their starting growth rate based on eight consecutive quarters. This would likely allow states to choose a higher base spending amount.

Is Jon Ossoff the new Scott Brown?

A special the middle of a big and controversial health care overhaul...for a seat no one ever thought would be competitive...which was last held by a major player in health care politics — haven't we seen this movie before?

If Democratic contender Jon Ossoff manages to squeeze out a victory tonight in Georgia's sixth congressional district, it'll be hard to deny some thematic similarities to Scott Brown's upset election in 2010. The two aren't identical, of course: Brown denied Democrats a 60th vote in the Senate; Republicans can easily afford to lose one House seat and still pass a bill.

But as canaries in coal mines go, the similarities could be telling. Brown's victory was all about the ACA, and Ossoff has made health care an integral part of his closing argument in the race for HHS secretary Tom Price's former seat.

Yes, but: Before Democrats start getting too excited about this analogy, though, remember: You all still passed your bill after Brown won — and held your Senate majority for another three years.

How states treat sexual assault and pre-existing conditions

An early wave of stories inaccurately suggested the House GOP health care bill would allow rape and sexual assault to be treated as pre-existing conditions. Those stories have been thoroughly debunked. Even with the House bill's state waivers, most states, we were told, have their own laws preventing sexual assault from being treated as a pre-existing condition.

State laws: Turns out that many of those laws are so vague that they probably wouldn't settle the issue. This map is based on an analysis from FiscalNote, a government relationship management software company. It found that 29 states have vague laws that only protect "victims of domestic violence," without any definition that includes sexual assault. That only matters in states that get state waivers, and only under certain conditions, but it's worth knowing. More here.

Lobbying for a children's Medicaid carveout

The Medicaid spending limits in the GOP health care bills are already forcing advocacy groups to ask for special protections. For example, the Children's Hospital Association sent out a June 15 memo saying it would try to get kids exempted from the Medicaid cuts if it couldn't stop the bill outright.

Key quote: "Our straightforward ask is to exempt children in Medicaid from the per capita caps and block grants," the group stated in the memo obtained by Vitals. "If we have priorities within this ask, we should at least exempt the disabled and medically complex children." Why it matters: It's easy to see how the Medicaid spending limits could lead to a competition between vulnerable groups, or at least tension if one group gets a carveout and the others don't. But Jim Kaufman, the group's VP of public policy, isn't trying to compete with other groups. He says he just wants to draw attention to the damage that spending limits could do to the 30 million children on Medicaid. "This is a bad bill for kids," he told us. What they found: When Kaufman went to Capitol Hill to talk to House Republicans before their vote, he said, some didn't know that Medicaid covered 30 million children: "They would say, 'Oh, no, all of the kids are in CHIP.' "

​Good news for ACA markets, sort of

Monday was a day of very mixed news for the ACA marketplaces, but at least no insurers pulled out. The highlights:

  • Medica, the last insurer standing in Iowa, announced it would stay in the marketplace after all — but it says it needs an average rate increase of 43%, the Des Moines Register reports.
  • Anthem, which had been noncommittal about selling ACA plans next year, said it will stay in Missouri for now — but warned that it could change any part of that decision at any time, per the St. Louis Post-Dispatch.
  • Premera will sell health plans in one of the two counties in Washington state that was in danger of having no insurance options.

​Higher premiums and fewer options

That's what the consulting firm Avalere Health expects to see in the exchanges next year, based on its review of eight states' early rate filings. Avalere's findings:

  • Premiums for "silver" plans (the middle-of-the-road option, and the most popular type of plan) are rising 18% next year, after a 12% increase this year.
  • 41% of counties could have only one insurer, up from 33% this year.
  • Insurers will likely keep moving into and out of certain markets through the summer, as the political situation around the exchanges becomes clearer.

Aetna embraces medication to combat opioid crisis

Aetna is going all in on medication-assisted treatment in response to the opioid epidemic, according to a letter CEO Mark Bertolini is sending today to a handful of Democratic senators. Bertolini highlights three goals the insurer hopes to achieve by 2022:

Reduce inappropriate opioid prescriptions by 50%.Increase by 50% the number of opioid addicts treated with medication-assisted treatment and other evidence-based treatments.Increase the number of enrollees with chronic pain who use alternative pain treatments by 50%.Go deeper: Aetna's embrace of medication-assisted treatment is a sharp contrast from some insurers' previous reluctance to cover the approach, which Bob Herman covered for Modern Healthcare. It also follows Tom Price's controversial comment saying medication-assisted treatment is "substituting one opioid for another."But Aetna has already worked to make medication more available: Earlier this year, it removed all pre-authorization requirements for certain products and put them on a preventive medicine list that reduces cost-sharing for patients.

What we're watching today: Did we mention the Georgia congressional special election is today? Also, the Senate Appropriations agriculture subcommittee holds a hearing on the FDA budget, 10:30 a.m. Eastern (unless Senate Democrats shut it down with their procedural protests). Livestream here.

What we're watching this week: The insurer filing deadline to provide ACA marketplace coverage, Wednesday. Also, Biotechnology Innovation Organization annual convention in San Diego, today through Thursday. Senate Appropriations subcommittee hearings on the VA budget, Wednesday, and the NIH budget, Thursday. Mylan annual shareholder meeting, Thursday.

Let us know what else you're watching: [email protected], [email protected]