Senate Republicans haven't ruled out extending enhanced Affordable Care Act subsidies via a reconciliation package next year, leaving a sliver of hope for a priority of hospitals, insurers, and provider and patient groups, Victoria reports.

Why it matters: If the subsidies are allowed to expire at the end of 2025, millions of Americans will lose health coverage or their premiums will rise, projections show.

• Republicans could pay a political price, too, since the subsidies have overwhelmingly benefited red states that haven't expanded Medicaid.

Republicans this week rejected an offer by Democrats to wrap a one-year extension of the ACA subsidies into a year-end health package.

What they're saying: But Republican senators over the past week told Victoria that the issue could still be in play next year.

• Incoming Senate Finance Chair Mike Crapo said that the subsidies could be included in reconciliation, adding that "what I can tell you is that everything is on the table" and "I don't know that that's been singled out yet, at least not in my deliberations."
• Soon-to-be HELP Chair Bill Cassidy said it was "kind of premature" for him to discuss prospects but said "it might be on the table, but I've not talked beyond it might be on the table."
• Senior Senate Finance member Chuck Grassley also told Victoria that he hadn't heard any discussions of the subsidies, saying "I think you got to figure everything's on the table" and "We'll wait until we get into negotiations deciding what" that would be.

But in the House, GOP members are much more reluctant to consider the possibility.

• Ways and Means Chair Jason Smith refused to answer when asked twice whether there's been talk of ACA subsidy extensions in reconciliation.
• House Budget Chair Jodey Arrington responded, "Hell no" when asked if he could envision a subsidy extension.

Still, even House Freedom Caucus members like Rep. Chip Roy see the need for health care, if not necessarily ACA subsidies, to be a part of the reconciliation discussion.

By the numbers: CBO last week estimated the effects of not extending the subsidies.

• Without an extension through 2026, the number of people without insurance would rise by 2.2 million that year. The number would increase to 3.8 million on average each year, from 2026 to 2034, if there's no permanent extension.
• Premiums are estimated to rise, from a 4.3% increase in 2026 to 7.7% in 2027 and 7.9% on average from 2026 to 2034.

The other side: Current Senate Finance Chair Ron Wyden told Axios that Republicans should find alternative coverage options if they let the subsidies expire.

• "If they don't want to find a way to provide targeted relief to help working people pay the bills, and not get sicker when they have illnesses, they have to tell us what they want to do," Wyden said.

The bottom line: That could mean a return of some of the health care plans conservatives have touted that don't provide coverage as comprehensive as ACA plans.

314 Action, an advocacy group that supports electing progressive doctors and scientists to Congress, is launching a six-figure digital ad campaign today against Robert F. Kennedy Jr.'s nomination for HHS secretary, in details first shared with Victoria.

Why it matters: The targeted online campaign marks one of the opening salvos in what's expected to be a bitter confirmation fight.

Zoom in: The six-figure ad buy is aimed at five GOP senators who are seen as likelier to oppose the nomination.

• They are Bill Cassidy, Susan Collins, John Cornyn, Lisa Murkowski and Thom Tillis. All but Murkowski are up for reelection in 2026.
• The campaign urges constituents to call their senators' offices and urge them to vote down the nomination.

What they're saying: "RFK Jr. has proven to be a dangerous extremist who is unfit to lead our nation's premier health agency," said Shaughnessy Naughton, president of 314 Action, in a statement.

• "If confirmed, RFK Jr. will immediately put the lives of families and children in danger and the health of millions of Americans at risk," she said.

Context: 314 Action supported Democratic doctors who ran for the House and won in this year's election, including incoming Reps. Maxine Dexter, Kelly Morrison and Herb Conaway.

A bipartisan group of lawmakers today unveiled legislation to split up PBMs and pharmacies, a sign of continued scrutiny of the drug supply intermediaries, Peter reports.

Why it matters: The measure shows the breadth of frustration with PBM business practices, with Sens. Elizabeth Warren and Josh Hawley joining forces.

• Reps. Jake Auchincloss and Diana Harshbarger are leading the House version.

What's inside: The bill would prohibit the parent company of a PBM or insurer from owning pharmacies.

• Corporations with both would have to divest the pharmacies within three years of enactment.

The measure targets consolidation in health care that critics say has driven up drug prices, limited patient choices and, in some cases, driven independent pharmacies out of business.

• Backers argue that PBMs use anticompetitive tactics that disadvantage independent pharmacies, steering business to their own affiliates.
• What they're saying: "PBMs have manipulated the market to enrich themselves — hiking up drug costs, cheating employers, and driving small pharmacies out of business," Warren said.

The other side: Greg Lopes, a spokesperson for the PBM trade group PCMA, said that "PBMs exist to serve patients by enabling employers and others to offer benefits."

• Members of Congress should "be thoughtful" before "they take away consumers' ability to access their medicines how and where they'd like," he added.

1. Trust deficit: The public trusts Anthony Fauci more than President-elect Trump and his incoming health team as a source of medical information, but some of RFK Jr.'s message is resonating, per a new Axios-Ipsos American Health Index.
2. AI regulation: Paragon Health Institute laid out guidelines that discourage misregulation of AI in health care, including avoiding duplication of existing technology safeguards.
3. FDA on nicotine: The Biden FDA is making a last-ditch attempt to reduce the amount of nicotine in cigarettes. More from NYT.